Clinical Simulation Exam 329 Questions with Verified Answers,100% CORRECT

Clinical Simulation Exam 329 Questions with Verified Answers COPD - CORRECT ANSWER Preventable and treatable disease state characterized by air flow limitation that is not fully reversible. Emphysema - CORRECT ANSWER Presence of permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibroisis Chronic bronchitis - CORRECT ANSWER Chronic productive cough for three months in each of two successive years in a pt for whom other causes of the productive cough have been excluded Etiology of COPD - CORRECT ANSWER - tobacco smoke -genetic predisposition - indoor and outdoor pollution Pt Assessment of Emphysema Pt (Primary assessment) - CORRECT ANSWER AKA pink puffer or Type A COPD Body build = thin, underweight Past medical history = Tobacco use Cough = Less common, muciod secretions Appearance of chest = Barrel chest, increased A-P diameter (Hoover's Sign) Respiratory Pattern = Dyspnea, pursed-lip breathing, accessory muscle use, especially during exacerbations Color= Often reddish Clubbing = Late stage Diagnostic Chest Percussion = Hyperresonant/ Tympanic note Breath Sounds = Diminished, prolonged expiration Body build of Type A COPD (pink puffer) Emphysema - CORRECT ANSWER Thin, underweight Past medical history for emphysema pts - CORRECT ANSWER Tobacco use Cough (Emphysema) - CORRECT ANSWER Less common, muciod secretions Appearance of the chest (Emphysema) - CORRECT ANSWER Barrel chest, increased A-P diameter Respiratory pattern ( Emphysema) - CORRECT ANSWER Dyspnea, pursed lip breathing, accessory muscle use, especially during exacerbations Color (Emphysema) - CORRECT ANSWER Often reddish Clubbing (Emphysema) - CORRECT ANSWER Late stage Diagnostic Chet Percussion (Emphysema) - CORRECT ANSWER Hyperresonant/tympanic note Breath sounds ( Emphysema) - CORRECT ANSWER Diminished, prolonged expiration Patient Assessment (Primary) Chronic Bronchitis - CORRECT ANSWER AKA Blue bloater Type B COPD Body build = Stocky, overweight Past Medical History = Tobacco use Cough = Productive, copious amounts, purulent secretions Chest Appearance = Ocassionally barrel chest Color = Cyanotic Clubbing = Common Diagnostic Chest Percussion = normal Breath Sounds = Rhonchi, crackles , wheezing Body build (Chronic Bronchitis) - CORRECT ANSWER Stocky, overweight Past Medical History (Chronic Bronchitis) - CORRECT ANSWER Tobacco use Cough (Chronic Bronchitis ) - CORRECT ANSWER Productive, copious amounts of purulent secretions Chest Appearance (Chronic Bronchitis) - CORRECT ANSWER Occasionally barrel chest Respiratory Pattern (Chronic Bronchitis ) - CORRECT ANSWER Use of accessory muscles less common Clubbing ( Chronic Bronchitis ) - CORRECT ANSWER Common Diagnostic Chest Percussion ( Chronic Bronchitis) - CORRECT ANSWER Normal Breath Sounds (Chronic Bronchitis ) - CORRECT ANSWER Rhonchi, crackles, wheezing Secondary Assessment Emphysema pt - CORRECT ANSWER Chest X-ray = translucent (dark) lung fields, depressed or flattened diaphragms, long and narrow heart, increased retrosternal air spaces, possibly hypertrophy or right ventricle ABG = Mild to moderate stages: Acute alveolar hyperventilation with hypoxemia Severe Stages: Chronic ventilatory failure with hypoxemia Pulmonary Function = Decreased flowrates (FEV1 , FEF 25-75%, FEF 200-1200, FEV1/FVC, and PEFR) Decreased DLCO CBC = Increased RBC/Hb/Hct in late stages Sputum = Normal Chest X-ray (Emphysema ) - CORRECT ANSWER Translucent (dark) lung fields, depressed or flattened diaphragms, long and narrow heart, increased retrosternal air space, possibly hypertrophy or right ventricle ABG (emphysema) - CORRECT ANSWER Mild to moderate stages: Acute alveolar hyperventilation with hypoxemia Severe stage: Chronic ventilatory failure with hypoxemia Pulmonary Function (Emphysema ) - CORRECT ANSWER Decreased flowrates, Decreased DLCO CBC (Emphysema) - CORRECT ANSWER Increased RBC/Hct/Hb in late stages Sputum (Emphysema) - CORRECT ANSWER Normal Secondary Assessment Chronic Bronchitis - CORRECT ANSWER AKA Type B Blue Bloater Chest X-ray = translucent (dark) lung fields, depressed or flattened diaphragms, possibly hypertrophy of right ventricle ABG = Mild to moderate stages: Acute alveolar hyperventilation with hypoxemia Severe stage: Chronic ventilatory failure with hypoxemia Pulmonary Function = Decreased flowrates, DLCO normal CBC = increased RBC/Hb/Hct in early and late stages Sputum = Often shows ; Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis Chest X-ray (Chronic Bronchitis) - CORRECT ANSWER Translucent lung fields, depressed or flattened diaphragms, possibly hypertrophy of the right ventricle ABG ( Chronic Bronchitis) - CORRECT ANSWER Mild to moderate stages: Acute alveolar hyperventilation with hypoxemia Severe stage: Chronic ventilatory failure with hypoxemia Pulmonary Function ( Chronic Bronchitis ) - CORRECT ANSWER Decreased flowrates, normal DLCO CBC (Chronic Bronchitis) - CORRECT ANSWER Increased RBC/Hb/Hct in early and late stages Sputum (Chronic Bronchitis ) - CORRECT ANSWER Often shows: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis Treatment for COPD - CORRECT ANSWER 1. Low flow o2 therapy Nasal cannula 1-2 L/min or 24-28% air entrainment mask Consider o2 conservation devices for home use 2. Bronchodilators (SABA, LABA, and anticholinergic) 3. Inhaled corticosteroids 4. Antibiotics if indicated by sputum culture 5. Bronchial hygiene as indicted 6. Referral to smoking cessation program, including nicotine replacement therapy 7. Consider NPPV for acute exacerbations of ventilatory failure 8. Refer pt family to pulmonary rehab ed programs which should include -Nutritional management - Avoiding infections -Exercise program - Methods to aid in secretion clearance -Home O2 and aerosol therapy -Appropriate use of medications 9. Annual flu vaccine Bronchiectasis (definition ) - CORRECT ANSWER Chronic dilation and distortion one of one or more bronchi as a result of excessive inflammation and destruction of the bronchial walls, blood vessels, elastic tissue and smooth muscle. Results in impaired mucocilary clearance causing accumulation of copious amounts of bronchial secretions -one or both lungs may be involved -Commonly limited to lobe or segment - Frequently found in lower lobes -Can create an obstructive or restrictive pattern or a combination of both Patient Assessment (Primary) for Bronchiectasis pt - CORRECT ANSWER Past Medical History = Recurrent pulmonary infections, Cystic Fibrosis, if Kartageners Syndrome Shortness of Breath = Present, possibly pursed lip breathing Cough = Productive with purulent foul smelling sputum, hemoptysis and 3 layer sputum, may be blood streaked Appearance of chest = Barrel chest, increased A-P diameter Respiratory Pattern = Accessory muscle usage Color = Cyanotic Appearance of the nail beds = clubbing Diagnostic Chest Percussion = Hyperresonant/tympanic note Breath Sounds = Wheezing, diminished breath sounds Past Medical History ( Bronchiectasis) - CORRECT ANSWER Recurrent pulmonary infections, Cystic Fibrosis, or Kartageners Syndrome Shortness of Breath (Bronchiectasis ) - CORRECT ANSWER Present, possibly pursed lip breathing Cough ( Bronchiectasis ) - CORRECT ANSWER Productive with purulent foul smelling sputum, hemoptysis and 3 layer sputum, may be blood streaked Appearance of chest (Bronchiectasis ) - CORRECT ANSWER Barrel chest, increased A-P diameter Respiratory Pattern ( Bronchiectasis ) - CORRECT ANSWER Accessory muscle usage Color ( Bronchiectasis ) - CORRECT ANSWER Cyanotic Appearance if the Nail Beds (Bronchiectasis ) - CORRECT ANSWER Clubbing Diagnostic Chest Percussion ( Bronchiectasis ) - CORRECT ANSWER Hyperresonant/tympanic note Breath Sounds ( Bronchiectasis ) - CORRECT ANSWER Wheezing, diminished breath sounds Patient Assessment ( Secondary) Bronchiectasis - CORRECT ANSWER Chest X-ray = hyperlucent lung fields, depressed or flattened diaphragm, enlarged or elongated heart ABG= mild to moderate : Acute alveolar hyperventilation with hypoxemia Severe: Chronic ventilatory failure with hypoxemia Pulmonary Function = Deceased flowrates CBC = increased RBC/Hb/Hct Sputum = May indicate infection Special Diagnostic Tests = CT scan - Increased bronchial wall opacity. Characteristic appearance of end on signet ring opacity chest X-ray (Bronchiectasis ) - CORRECT ANSWER Hyperlucent lung fields, depressed or flattened diaphragm, enlarged or elongated heart ABG ( Bronchiectasis ) - CORRECT ANSWER Mild to moderate : acute alveolar hyperventilation with hypoxemia Severe : Chronic ventilatory failure with hypoxemia Pulmonary Function ( Bronchiectasis ) - CORRECT ANSWER Decreased flowrates CBC ( Bronchiectasis ) - CORRECT ANSWER Increased RBC/Hb/Hct Sputum (Bronchiectasis ) - CORRECT ANSWER May indicate infection Special Diagnostic Tests ( Bronchiectasis ) - CORRECT ANSWER CT scan - Increased bronchial wall opacity. Characteristic appearance of end on signet ring opacity Treatment for Bronchiectasis - CORRECT ANSWER 1. Bronchopulmonary hygiene 2. Lung expansion therapy 3. antibiotics for infection 4. Expectorants 5. Aerosolized medications -Sympathomimetic agents -Parasympatholytic agents 6. Surgical resection of involved segments if necessary 7. Oxygen for hypoxemia 8. Mechanical ventilation for reversible acute ventilatory failure 9. Childhood vaccines, yearly flu vaccines 10. Avoid triggers: - Upper respiratory infections -Smoking -Polluted environments Chest Trauma definition - CORRECT ANSWER Any type of trauma to the chest wall Flail Chest definition - CORRECT ANSWER The result of double fractures of at least three or more adjacent ribs, causing the thoracic cage to become unstable (flail) Etiology of Chest trauma or flail chest - CORRECT ANSWER -industrial accidents -vehicle accidents -falls -Violence -Blast injury Pt assessment (Primary) Chest Trauma/Flail Chest - CORRECT ANSWER Past Medical History = History of injury Cough = Possibly hemoptysis Appearance of Chest = Bruising over area involved Respiratory Pattern = Paradoxical chest movement - flail chest. Shallow rapid respirations, severe chest pain Color = Cyanotic Breath Sounds = Diminished over the affected area Vital Signs = Elevated heart rate and blood pressure Past Medical History ( Chest Trauma) - CORRECT ANSWER History of injury Cough ( Chest Trauma) - CORRECT ANSWER Possibly hemoptysis Appearance of chest ( Chest Trauma ) - CORRECT ANSWER Paradoxical chest movement - flail chest Shallow rapid respirations, severe chest pain Color ( Chest Trauma ) - CORRECT ANSWER Cyanotic Breath Sounds (Chest Trauma) - CORRECT ANSWER Diminished Sounds over the affected area Vital Signs (Chest trauma) - CORRECT ANSWER Elevated heart rate and blood pressure Pt assessment (secondary) chest trauma/flail chest - CORRECT ANSWER Chest X-ray = increased opacity from lung compression, rib fractures ABG = Acute alveolar hyperventilation with hypoxemia Pulmonary Function = Decreased volumes and capacities Chest X-ray (chest trauma ) - CORRECT ANSWER Increased opacity from lung compression, rib fractures ABG= Acute alveolar hyperventilation with hypoxemia - CORRECT ANSWER Pulmonary Function = decreased volumes and capacities Treatment for chest trauma/flail chest - CORRECT ANSWER - O2 therapy for hypoxemia -Analgesics - Hyperinflation therapy -Mechanical Ventilation with PEEP or severe cases -Severe cases may require surgical stabilization of the chest wall -Brochoplumonary hygiene -Prevention of PNA Pneumothorax definition - CORRECT ANSWER Gar or free air accumulated in the pleural space Pt assessment (Primary) pneumothorax - CORRECT ANSWER Past medical history = severe chest pain Appearance of the chest = Tracheal and/or mediastinal shift away from the affected side, increased volume on the affected side, bruising over the effected side Color = cyanotic Diagnostic Chest Percussion = Hyperresonant /tympanic note -Breath sounds = Diminished or absent on affected side -vital signs = Small pneumo: Tachycardia, hypertension large pneumo: Bradycardia, hypotension Past medical history ( Pneumothorax) - CORRECT ANSWER Severe chest pain Appearance of Chest (Pneumothorax) - CORRECT ANSWER Tracheal and/or mediastinal shift away from affected side, increased volume on affected side, bruising over the affected area Respiratory Pattern ( Pneumothorax) - CORRECT ANSWER Tachypnea, reduced movement on affected side Color ( pneumothorax) - CORRECT ANSWER Cyanotic Diagnostic Chest Percussion (pneumothorax) - CORRECT ANSWER Hyperresonant / tympanic note Breath Sounds ( Pneumothorax) - CORRECT ANSWER Diminished or absent on affected side Vital signs (Pneumothorax ) - CORRECT ANSWER Small pneumothorax: Tachycardia, hypertension Large pneumothorax: Bradycardia, hypotension Pt assessment (Secondary) Pneumothorax - CORRECT ANSWER Chest X-ray = hyperlucency with absence of vascular markings on the affected side, tracheal shift to the unaffected side, depressed diaphragm, lung collapse Treatment for pneumothorax - CORRECT ANSWER -Small pneumo may only reaffirm bed rest and limited physical activity. Absorption usually occurs within 30 days. -Large pneumo should be evacuated by chest tube -Needle aspiration of the chest necessary if patient is unstable (bradycardia, hypotension, cyanosis, etc) -Oxygen for hypoxemia -Hyperinflation therapy after chest tube insertion -Mechanical ventilation with PEEP for acute ventilatory failure Hemothorax definition - CORRECT ANSWER Blood accumulated in the plural space Etiology of a hemothorax - CORRECT ANSWER traumatic - obvious injury Pt assessment (Primary) Hemothoarx - CORRECT ANSWER Past Medical History = Severe chest pain Vital Signs = Elevated heart rate and blood pressure Cough = Productive cough (hemoptysis) Appearance of the chest = Tracheal and/or mediastinal shift away from the affected side,bruising over the affected area Respiratory Pattern = Tachypnea, Dyspnea depending on severity Color= Cyanotic Diagnostic Chest Percussion = Flat/full percussion note, decreased tactile and vocal free iTunes Breath sounds = Diminished or absent of the affected side, possibly pleural friction rub Pt assessment (Secondary) Hemothorax - CORRECT ANSWER Chest X-ray = increased radio density, tracheal shift away from affected side ABG= Acute alveolar hyperventilation with hypoxemia CBC= Reduced RBC/Hb/Hct Treatment for Hemothorax - CORRECT ANSWER -Thoracentesis or chest tube to drain blood -Oxygen for hypoxemia -Hyperinflation therapy after chest tube insertion -Mechanical Ventilation with PEEP for acute ventilatory failure Thermal Injuries definition - CORRECT ANSWER The inhalation of smoke and hot gases often accompanied by body surface burns -May lead to complete airway obstruction. Should be suspected in the presence of any type of fire Etiology of thermal injury - CORRECT ANSWER -Fire victims -Firefighters -Inhalation of car exhaust Pt assessment (Primary) thermal injury - CORRECT ANSWER Past medical history = Fireman or pts pulled from a burning building, pts found sitting in garage with car running, trash fires Shortness of breath = May be present Cough = Excessive thick, black, sooty secretions Respiratory Pattern = Tachypnea Color = Cyanosis, Cherry Red (suspect CO poisoning ) Level of consciousness = Alert, may be confused, unresponsive Breath Sounds = Normal in early stages, may present with wheezing, crackles, or rhonchi, inspiratory stridor may indicate airway obstruction Physical appearance = Anxious, surface burns, singed facial hair, clack soot marks, obvious pharyngeal swelling and edema, hoarseness , altered voice, dysphasia Vital Signs = Increased HR , BP, QT, pulse oximetry not accurate if CO poisoning present Past medical history - thermal injury - CORRECT ANSWER Fireman or pts pulled for a burning building, pts found sitting in garage with the car running, trash fires Shortness in breath - thermal injuires - CORRECT ANSWER May be present Cough - thermal injury - CORRECT ANSWER Excessive thick, black, sooty secretions Respiratory Pattern - thermal injury - CORRECT ANSWER Tachypnea Color - thermal injury - CORRECT ANSWER Cyanosis, cherry red = suspect CO poisoning Level of Consciousness - thermal injury - CORRECT ANSWER Alert, may be confused, unresponsive Breath Sounds - thermal injury - CORRECT ANSWER Normal in early stages, may present with wheezing, crackles, or rhonchi, inspiratory stridor may indicate airway obstruction Physical Appearance - thermal injury - CORRECT ANSWER Anxious, surface burns, singed facial hair, black soot marks, obvious pharyngeal swelling, and edema, hoarseness, altered voice and dysphagia Vital signs - thermal injury - CORRECT ANSWER Increased HR,BP, QT, Sp02 not accurate if CO poisoning is present Secondary Pt Assessment - thermal injury - CORRECT ANSWER Chest X-ray = normal in early stages, pulmonary edema/ARDS late stages ABG= Acute hyperventilation with hypoxemia Pulmonary Function = Decreased volumes and flowrates and decreased DLCO Special Tests = CoHb Levels measured by co-oximetry Chest X-ray - thermal injury - CORRECT ANSWER Normal in early stages Pulmonary edema/ARDS in late stages ABG - thermal injury - CORRECT ANSWER Acute alveolar hyperventilation with hypoxemia Pulmonary Function - thermal injury - CORRECT ANSWER Decreased volumes and flowrates, decreased DLCO Special Tests - Thermal injury - CORRECT ANSWER COHb levels ensured by co-oximeter Treatment for thermal injury - CORRECT ANSWER -Immediate assessment of the pts airway and respiratory and cardiovascular status Elective intubation should be performed for the pts who have inhaled hot gases or demonstrate signs of impending upper airway obstruction (marked or severe distress/stridor) -O2 therapy at 100% -Hyperbaric O2 therapy for CO poisoning (if available) -Evaluate depth and percent of burns -Immediate insertion of an IV line -Isolation room -Monitor ABG, electrolytes, and fluid levels -Monitor for signs of infection -Bronchoscopyto clear airways of mucus plugs and evaluation of the upper airways -Mechanical ventilation for ventilatory failure -Pulmonary hygiene -hyperinflation therapy -Aerolsolized medications 1. Bronchodilators 2. Mucolytics 3. Anti-inflammatory agents ARDS definition - CORRECT ANSWER An illness or injury to the lungs that results in reduced lung compliance and refactory hypoxemia Etiology of ARDS - CORRECT ANSWER -Aspiration -Trauma -Drug overdose -Fluid overload -Inhalation of toxins and irritants -shock Primary pt assessment - ARDS - CORRECT ANSWER Past medical history = Aspiration , trauma, drug overdose, fluid overload, inhalation of toxins and irritants, shock Cough = Non productive Respiratory Pattern = Tachypnea, substernal and/or intercostal retractions Color = Cyanotic Diagnostic Chest Percussion = Flat/dull note Breath Sounds = Bronchial, crackles Vital Signs = Tachycardia, hypertension Past Medical History - ARDS - CORRECT ANSWER Aspiration , trauma, drug overdose, fluid overload, inhalation of toxins and irritants, shock Cough - ARDS - CORRECT ANSWER Non productive Respiratory Pattern- ARDS - CORRECT ANSWER Tachypnea, substernal and/or intercostal retractions Color - ARDS - CORRECT ANSWER Cyanotic Diagnostic Chest Percussion - ARDS - CORRECT ANSWER Flat/dull notes Breath Sounds - ARDS - CORRECT ANSWER Bronchial, crackles Vital Signs - ARDS - CORRECT ANSWER Tachycardia, hypertension Secondary pt assessment - ARDS - CORRECT ANSWER Chest X-ray =diffuse alveolar infiltrates with a honeycomb or ground glass appearance, radiopacity ABG = Refractory hypoxemia acute alveolar hyperventilation with hypoxemia Pulmonary Function = Decreased volumes and capacities Sputum. = May indicate infection Special Tests = Hemodynamic monitoring reveals elevated PAP with normal PCWP ABG - ARDS - CORRECT ANSWER Refractory hypoxemia acute alveolar hyperventilation with hypoxemia Pulmonary Function - ARDS - CORRECT ANSWER Decreased volumes and capacities Sputum - ARDS - CORRECT ANSWER May indicate infection Special Tests - ARDS - CORRECT ANSWER Hemodynamic monitoring reveals elevated PAP with normal PCWP Treatment for ARDS - CORRECT ANSWER -Treat underlying cause -O2 therapy 1. Increase Fio2 as high as .60, then add CPAP/PEEP 2. When pt improves, titrate Fi02 to below .60 the reduce CPAP/PEEP -Closely monitor hemodynamics -Hyperinflation therapy for atelectasis -Implement ARDSnet ventilator protocol 1. Reduce Vt to 6ml/kg 2. Maintain plateau pressure 30 cm H20 3. Recruitment maneuvers - Consider alternative modes of ventilation 1. Inverse Ratio Ventilation 2. Airway Pressure Release Ventilation 3. Pressure Regulated Volume Control 4. High Frequency Ventilation 5. Permissive hypercapnia 6. Pulmonary vasodilator -Consider prone positioning to improve oxygenation Neurologic/Neuromuscular Conditions - CORRECT ANSWER -Myasthenia Gravis -Guilain-Barre Syndrome -Drug Ovedose -Stroke, Cerebral Infarction, Cerebrovascular Accident, Transient Ischemic Attack -ALS What to monitor to watch for ventilatory failure nuero pts? - CORRECT ANSWER Spontaneous Vt VC MIP If values fall below acceptable level, institute mechanical ventilation Myasthenia Gravis definition - CORRECT ANSWER Chronic disorder of the neuromuscular junction that interferes with chemical transmission of acetylcholine A descending paralysis that moves from Mind to ground Etiology of Myasthenia Gravis - CORRECT ANSWER Related to circulating antibodies of the autoimmune system. Clincal manifestations are provoked by: Emotional Stress Physical stress Exposure to extreme temp changes Pregnancy Febrile illness Primary patient assessment for Myasthenia Gravis - CORRECT ANSWER Past medical history = Gradual onset of weakness, may have previous admissions of Myasthenia Gravis Physical Appearance = General weakness that improves with rest, drooping eyelids (ptosis), double vision (diplopia), difficulty swallowing (dysphagia) Respiratory Pattern = Shallow breathing Breath Sounds = diminished Past Medical history - Myasthenia Gravis - CORRECT ANSWER Gradual onset of weakness, may have previous admissions for Myasthenia Gravis Physical Appearance - Myasthenia Gravis - CORRECT ANSWER General weakness that improves with rest, ptosis, diplopia, dysphagia Respiratory Pattern - Myasthenia Gravis - CORRECT ANSWER Shallow Breathing Breath Sounds - Myasthenia Gravis - CORRECT ANSWER Diminished Secondary Assessment - Myasthenia Gravis - CORRECT ANSWER Special testing = Edrophonium (Tenslion) Challange, Electromyography, Blood test for Ach Receptor Antibodies, Ice Pack test Spontaneous Ventilatory Parameters = Decreasing Vt, VC, MIP ABG = Acute ventilatory failure with hypoxemia. What for vent failure (PaCo2 45 torr) Pulmonary Function = Reduced volumes Special testing - Myasthenia Gravis - CORRECT ANSWER Edrophonim (Tenslion) Challange, Electromyography, Blood test for Ach Receptor Antibodies, Ice pack test Spontaneous Vent Parameters - Myasthenia Gravis - CORRECT ANSWER Decreasing Vt, VC, MIP ABG - Myasthenia Gravis - CORRECT ANSWER Acute vent failure with hypoxemia. Watch for vent failure PaCo2 of 45 torr. Pumonary Function Myastenia Gravis - CORRECT ANSWER Reduced volumes Edrophonium (Tensilon ) Challenge - CORRECT ANSWER Test to diagnose and monitor Myasthenia Gravis If VC, Vt, MIP and weakness improves: -Referred to as Myasthenic Crisis, indicating more of this type of drug needs to be given If VC, Vt, MIP and weakness worsen: -Referred to as a Cholinergic crisis, indicating too much of the drug has been given Give atropine to relieve symptoms of cholinergic crisis Treatment for Myasthenia Gravis - CORRECT ANSWER -Closely monitor Vt, VC, MIP Incubate and institute mechanical ventilation when indicated -Bedrest restriction and soft diet to reduce symptoms -Oxygen therapy for hypoxemia -Pulmonary hygiene -Other treatment modalities: Corticosteroids in severe cases Thymectomy Plasmapheresis Guillain-Barré syndrome definition - CORRECT ANSWER Rare autoimmune disorder of the peripheral nervous system, Most likely an immune disorder that causes inflammation and deterioration of the pts peripheral nervous system -Ground to brain Etiology of Gillian-Barre Syndrome - CORRECT ANSWER Precise cause is unknown Onset frequently occurs 1-4 weeks after a febrile illness caused by a mild respiratory or gastrointestinal viral or bacterial infection Primary assessment for Guillian Barre Syndrome - CORRECT ANSWER Past medical history = Febrile illness, often viral in nature Physical appearance = Acute weakness, especially in the legs Respiratory Pattern = Shallow breathing Breath Sounds = Dimished with crackles and rhonchi Past medical history - Guillain-Barre Syndrome - CORRECT ANSWER Febrile illness, often viral in nature Physical Appearance - Guillain-Barre Syndrome - CORRECT ANSWER Acute weakness, especially in the legs Respiratory Pattern - Guillain-Barre - CORRECT ANSWER Shallow breathing Breath Sounds - Guillain Barre - CORRECT ANSWER Diminished with crackles and rhonchi Secondary Assessment - Guillain Barre Syndrome - CORRECT ANSWER Spontaneous ventilatory Parameters = Decreasing Vt, MIP, VC ABG = Acute ventilatory failure with hypoxemia, watch for vent failure (PaCo2 45 torr) Pulmonary Function = Reduced volumes Special Tests = Lumbar puncture - high protein level in CSF, electromyography, elevated IgM levels Spontaneous vent parameters - Guillain Barre - CORRECT ANSWER Decreasing Vt, VC, and MIP ABG - Guillain Barre - CORRECT ANSWER Acute vent failure with hypoxemia, watch for vent failure (PaCo2 45 torr) Pulmonary Function - Guillain Barre - CORRECT ANSWER Reduced volumes Special Tests - Guillain Barre - CORRECT ANSWER Lumbar puncture Abnormal electromyography elevated IgM levels Treatment for Guillain Barre - CORRECT ANSWER -Directed at stabilization of vital signs and supportive care -Initially pts should be carefully monitored and manged in the ICU -Closely monitor Vt, VC, MIP Intubate and institute mechanical ventilation when indicated -O2 therapy for hypoxemia -Hyperinflation therapy -Pulmonary hygiene -Plasmapheresis -Other treatment modalities: Anti-coagulant therapy, physical therapy, corticorsteriods Drug Overdose definition - CORRECT ANSWER The intentional misuse or accidental overuse of medication that exceeds the recommended medical dose. Etiology of drug overdose - CORRECT ANSWER History is often the most significant finding. Mental illness (depression, addiction) Primary Assessment of drug overdose - CORRECT ANSWER Past medical History = Previous admissions for overdose, found by family, friends, ect Respiratory pattern = slow, shallow respirations Physical Appearance = Altered level of consciousness Breath Sounds = Diminished throughout Past medical history - drug overdose - CORRECT ANSWER previous admissions for overdose Respiratory pattern - drug overdose - CORRECT ANSWER shallow, slow Physical appearance - drug overdose - CORRECT ANSWER Altered level of consciousness Breath Sounds - drug over dose - CORRECT ANSWER diminished throughout Secondary assessment for drug overdose - CORRECT ANSWER drug toxicology Monitor results of basic laboratory testing Treatment for drug overdose - CORRECT ANSWER Placement of an artificial airway is the first priority Mechanical ventilation for vent failure Naloxone (Narcan) used to reverse narcotic overdose Acetylcsteine used for acetaminophen overdose Stroke/Cerebral Infarction/Cerebrovascular Accident (CVA)/Transient Attack (TIA) definition - CORRECT ANSWER A portion of the brain loses blood supply as a result of a vascular occlusion or hemorrhage Etiology - Stroke/Cerebral Infarction/Cerebrovascular Accident (CVA)/Transient Attack (TIA) definition - CORRECT ANSWER Cerebral thrombi or emboli Atherosclerosis Hypertension Primary Pt Assessment - Stroke/Cerebral Infarction/Cerebrovascular Accident (CVA)/Transient Attack (TIA) definition - CORRECT ANSWER Past medical history = Cerebral thrombi or emboli Atherosclerosis Hypertension Respiratory Pattern = Cheyne Stokes Physical Appearance = Motor and speech loss Secondary pt assessment - Stroke/Cerebral Infarction/Cerebrovascular Accident (CVA)/Transient Attack (TIA) definition - CORRECT ANSWER Monitor results of basic lab testing Special Tests = CT/MRI of the brain, cerebral angiogram Intracranial Pressure monitor = ICP may be elevated Treatment of Stroke/Cerebral Infarction/Cerebrovascular Accident (CVA)/Transient Attack (TIA) definition - CORRECT ANSWER -Treatment should be initiated within 6 hrs of symptom onset -Drug therapy : Anticouagulation therapy, Vasodilators, Thrombolytic therapy (for acute ischemic stroke) -Mechanical ventilation for vent failure or to reduce ICP Polio/ALS/Muscular Dystrophy - CORRECT ANSWER Neuromuscular disorder that involve loss of voluntary muscle action Etiology -Polio/ALS/Muscular Dystrophy - CORRECT ANSWER Viral infection (Polio) Genetic disorder (muscular dystrophy ) Puncture wound (Tetanus/Botulism) Primary Assessment for Polio/ALS/Muscular Dystrophy - CORRECT ANSWER Past Medical History = History of present illness, previous admission for disease Current medications = Drug therapy for specific disease Secondary Assessment for Polio/ALS/Muscular Dystrophy - CORRECT ANSWER ABG = Watch for vent failure Spontaneous vent parameters = Decreasing Vt, VC, MIP Treatment for Polio/ALS/Muscular Dystrophy - CORRECT ANSWER -Closely monitor Vt, VC, MIP Intubate and institute mechanical vent as indicated -Drug therapy : Paralyzing agents to relax jaw for intubation and ventilation in case of tetanus/botulism Chest Pain/Myocardial Infarction - CORRECT ANSWER Unstable angina is a form of acute coronary syndrome that results in reversible myocardial ischemia and is a sign of impending failure. Myocardial infarction: Interruption of coronary blood flow for an extended period of time causing irreversible damage to the heart muscle Sudden cardiac death can occur in either pathology The history of the current event is often the most significant finding Etiology - Chest Pain/Myocardial Infarction - CORRECT ANSWER Heart disease Hypertension Thrombus Primary Pt Assessment for Chest Pain/Myocardial Infarction - CORRECT ANSWER Past medical history = Chest pain, family & social history, history of the present illness. Shortness of Breath = May be present Respiratory pattern = May be tachypneic Color = Possible cyanosis Breath Sounds = Crackles if ventricular failure is present Physical Appearance = Diaphoretic, anxious, nauseous Vital Signs = Elevated blood pressure, pulse Secondary Assessment Chest Pain/Myocardial Infarction - CORRECT ANSWER ABG = Hypoxemia Electrolytes = Hyperkalemia or hypokalemia Electrocardiogram = Arrhythmias with S-T segment changes and significant Q waves Special Tests = Cardiac enzymes Treatment for Chest Pain/Myocardial Infarction - CORRECT ANSWER Immediate O2 therapy at 100% Closely monitor vital signs, SpO2, ECG Drug therapy : Asprin, Anti-arrhythmic agents (amniodarone, procainamide, atropine), nitrates for chest pain, maintain blood pressure with fluid or vasopressors (dopamine), defibrillate for pulseless ventricular tachy or fibrilation. CHF/Pulmonary Edema - CORRECT ANSWER CHF: Abnoraml condition that reflects impaired cardiac pumping Pulmonary edmea: Excessive movement of fluid from the pulmonary vascular system to the extravascular system and air spaces of the lungs Etiology - CHF - CORRECT ANSWER myocardial infarction ischemic heart disease cardiomyopathy Etiology - pulmoary edema - CORRECT ANSWER Cardiogenic pulmonary edema: increased pulmonary capillary hydrostatic pressure, usually due to CHF Non-cardiogenic pulmonary edema: increased capillary permeability, ARDS Primary Assessment - CHF/Pulmonary edema - CORRECT ANSWER Past medical history = Gradual or sudden onset Cough = Pink frothy secretions Respiratory pattern - Tachypneic, orthopnea Color = cyanotic Diagnostic chest percussion = Flat or dull percussion note Breath sounds = Crackles, rhonchi Physical appearance = Pedal edema, diaphoresis, anxious, jugular venous distension Vital signs = tachycardia Past medical history - CHF/Pulmonary Edema - CORRECT ANSWER Gradual or sudden onset Cough - CHF/Pulmonary Edema - CORRECT ANSWER Pink frothy secretions Respiratory pattern - CHF/Pulmonary edmea - CORRECT ANSWER Tachypneic, orthopnea Color - CHF/Pulmonary Edema - CORRECT ANSWER Cyanotic Diagnostic Chest Percussion - CHF/Pulmonary Edema - CORRECT ANSWER Dull/Flat note Breath Sounds - CHF/Pulmonary Edema - CORRECT ANSWER Crackles, rhonchi Physical Appearance - CHF/Pulmonary Edema - CORRECT ANSWER Pedal edema, diaphoresis, anxious, jugular venous distension Vital Signs - CHF/Pulmonary Edema - CORRECT ANSWER Tachycardia Secondary Assessment - CHF/Pulmonary Edema - CORRECT ANSWER Chest x-ray = Fluffy opacities, butterfly or batwing pattern, Kerly lines ABG = Respiratpry alkalosis with hypoxemia Pulmonary Function = Reduced volumes and capacities, normal FEV1/FVC ratio Electrolytes = Decreased K+ and Na+ Hemodynamics = Increased PCWP with CHF, Increased PAP Special Tests = Elevated brain natriuretic peptide (BNP) with CHF Chest x-ray - CHF/Pulmonary Edema - CORRECT ANSWER Fluffy opacities, butterfly or batwing pattern ABG - CHF/Pulmonary Edema - CORRECT ANSWER Respiratory alkalosis with hypoxemia Pulmonary Function - CHF/Pulmonary Edema - CORRECT ANSWER Reduced volumes and capacities, normal FEV1/FVC ratio Sputum - CHF/Pulmonary Edema - CORRECT ANSWER Pink frothy secretions Electrolytes - CHF/Pulmonary Edema - CORRECT ANSWER Decreased K+ and N+ Hemodynamics - CHF/Pulmonary Edema - CORRECT ANSWER Increased PCWP with CHF, increased PAP Special Tests - CHF/Pulmonary Edema - CORRECT ANSWER Elevated brain natriuretic peptide (BNP) with CHF Treatment for CHF/Pulmonary Edema - CORRECT ANSWER Immediate O2 therapy at 100% Closely monitor vital signs and place pt in Fowler's position IPPB with 100% O2 Drug therapy: Diuretics Furosemide (Lasix) Bumetanide (Bumex) Spironlactone (Aldactone) Positive inotropic agents: Digitalis Digoxin Dopamine Low dose amniodarone Analgesic/Sedative Morphine Afterload reduction agents Morphine Nitroglycerin Nitroprusside ACE inhibitor Antidysrhythmic agents Atropine for bradcardia Procainmide, metoprol, or bretylium for tachycardia Electrolyte replacement Potassium Sodium CPAP if indicated to support ventilation Mechanical ventilation with PEEP for vent failure Arrhythmias - CORRECT ANSWER Irregularities in the cardiac rhythm Etiology - arrhythmias - CORRECT ANSWER Hypoxemia, ischemia, electrolyte embalance, conduction disorders Treatment - arrhythmias - CORRECT ANSWER PVC = Treat with O2 and consider causes Ventricular fibrillation and pulseless ventricular tachycardia require immediate defibrillation Atrial flutter fibrillation, and ventricular tachycardia with a pulse are not life threatening. Consider synchronized cardioversion Shock - CORRECT ANSWER Occurs when the cardiovascular system fails to adequately perfuse tissues that result in widespread impalement of cellular metabolism. A reduction in blood flow to the tissues that is adequate to sustain life. Etiology of shock - CORRECT ANSWER Cardiogenic = Heart failure Neurogenic or Vasogenic = Alterations in vascular smooth muscle tone Anaphylactic = Hypersensitivity Septic = Infection Hypovolemic = insufficient intravascular fluid volume Traumatic = Components of hypovolemic and septic shock Primary Assessment - shock - CORRECT ANSWER Past medical History =History of present illness Shortness of breath = Increased Respiratory Pattern = Tachypnea Color = Pale, cyanotic Physical Appearance = Cold, clammy, lethargic, unresponsive, nausea, dizziness, diaphoretic, poor capillary refill Vital Signs = Tachycardia, hypothermic, hypotensive Past medical history - shock - CORRECT ANSWER history of present illness Shortness of breath - shock - CORRECT ANSWER increased Respiratory Pattern - shock - CORRECT ANSWER Tachypnea Color - shock - CORRECT ANSWER pale, cyanotic Physical Appearance - shock - CORRECT ANSWER cold, clammy, lethargic, unresponsive, nausea, dizziness, diaphoretic, poor capillary refill Vital Signs - shock - CORRECT ANSWER Tachycardia, Hypothermic, hypotensive Secondary Assessment - shock - CORRECT ANSWER ABG= Hypoxemia Hemodynamics =Decreased CVP, PAP, PCWP, QT Urine output = decreased Treatment for shock - CORRECT ANSWER Mechanical ventilation for vent failure Drug therapy Vasopressors for vasogenic shock Digitalis, digoxin for heart failure Antibotics for infection Treat hypovolemia IV fluids Blood transfusion Cor Pulmonale - CORRECT ANSWER Consists of right ventricular enlargement and is secondary to pulmonary hypertension from disorders of the chest wall or lungs Etiology of Cor Pulmonale - CORRECT ANSWER Increased right ventricular workload as a result of pulmonary hypertension causing hypertrophy of the right ventricle. Often caused by COPD Primary pt Assessment - Cor Pulmonale - CORRECT ANSWER Past Medical History = Chronic lung disease Shortness of Breath = Dyspnea Appearance of the Chest = Increased A-P diameter with obstructive lung disease Physical Appearance = Distended neck veins, chest pain, peripheral edema Past Medical History - Cor Pulmonale - CORRECT ANSWER Chronic lung disease Shortness of Breath - Cor Pulmonale - CORRECT ANSWER Dyspnea Appearance of the Chest - Cor pulmonale - CORRECT ANSWER Increased A- P diameter with obstructive lung disease Physical appearance - Cor Pulmonale - CORRECT ANSWER Distended neck vein, chest pain, peripheral edema Secondary Assessment - Cor Pulmonale - CORRECT ANSWER Hemodynamics = Increased CVP, decreased Qt with exercise Electrocardiogram = Right ventricular hypertrophy Treatment - Cor Pulmonale - CORRECT ANSWER O2 therapy Closely monitor vital signs Treat underlying causes Decrease workload of the right ventricle by lowering the PAP Drug therapy: Digitalis, Diuretics, Pulmonary vasodilators (nitric oxide) Pulmonary Embolism - CORRECT ANSWER A blood clot or obstruction that becomes dislodged from somewhere else in the body and obstructs the pulmonary vasculature Results in a deadspace condition (Ventilation without perfusion) Etiology - PE - CORRECT ANSWER Blood clots Fat/Air emboli Fractures Recent surgery Venous Statis (immobility) Primary Pt assessment - PE - CORRECT ANSWER Past medical history = Sudden onset, prolonged bedrest, trauma, venous stasis Shortness of breath = May be present Cough = Hemoptysis Respiratory Pattern = Tachypnea Color = Cyanosis Breath sounds = Wheezing, crackles, pleural friction rub Physical Appearance = Anxious, diaphoretic Vital Signs = Tachycardia, chest pain, decreased BP Past Medical History - PE - CORRECT ANSWER Sudden onset, prolonged bedrest, trauma, venous stasis Shortness of Breath - PE - CORRECT ANSWER May be present Cough - PE - CORRECT ANSWER Hemoptysis Respiratory pattern - PE - CORRECT ANSWER Tachypnea Color - PE - CORRECT ANSWER Cyanotic Breath Sounds - PE - CORRECT ANSWER Wheezing, crackles, pleural friction rub Physical Appearance - PE - CORRECT ANSWER anxious, diaphoretic Vital Signs - PE - CORRECT ANSWER Tachycardia, chest pain, decreased BP Secondary Assessment - PE - CORRECT ANSWER Chest x-ray = May be normal or demonstrate a wedge shape infiltrate ABG = Respiratory alkalosis with hypoxemia Sputum = Blood tinged Hemodynamics = Increased PAP Special tests = Spiral CT, V/Q scan, pulmonary angiogram, D-dimer Capnography (PeCO2) = Decreasing PeCO2 with normal PaCO2 Vd/Vt ratio = Increased Treatment for PE - CORRECT ANSWER O2 therapy at 100% to maintain PaO2 80 Closely monitor vital signs and ABG Coagulation studies Drug therapy: Low dose heparin, warfarin, Analgesic to relieve chest pain Digitalis, digoxin to maintain circulation Thrombolytic agents- urokinase, streptpkinase, tPA Active and passive exercises Early ambulation Anti-embolism stockings Intermittent pneumatic compression devices Surgical Options : Embolectomy, Vena cava interruption with sutures, Greenfield filter with IVC Peripheral Vascular Disease (PVD) - CORRECT ANSWER An abnormal condition causing partial or complete obstruction of blood flow to or from the arteries or veins outside the chest. Examples of PVD are arteriosclerosis, atherosclerosis, deep venous thrombosis, ect Etilogy - PVD - CORRECT ANSWER Diabetes Hypertension Cigarette smoking Treatment - PVD - CORRECT ANSWER -treatment of severe cases may require amputation of gangrenous body parts -less severe peripheral vascular problems may be treated by eliminating contributing factors, especially cigarette smoking, and by the administration various drugs, such as salicylates and anticoagulants Croup (Laryngotracheobronchitis) - CORRECT ANSWER General term used to describe the inspiratory barking sound associated with the partial airway obstruction that develops in laryngotracheobronchitis (subglottic croup). -Clinically the inspiratory sound heard in croup is also called inspiratory stidor. -Laryngotracheobronchitis (LTB) is used as a synonym for "Classic" subglottic croup -LTB is an inflammatory process that causes edema Etiology of LTB - CORRECT ANSWER Caused by Parainfluenza viruses 1, 2, and 3 transmitted by aerosol droplets Primary Pt Assessment LTB - CORRECT ANSWER Past Medical History = Recent cold that developed gradually into a barking cough over 2-3 days, most common in the fall and winter Cough = barking, hoarse voice Appearance of chest = Use of accessory muscles during inspiration, substernal and intercostal retractions Respiratory Pattern = Tachypnea Color = Cyanosis Breath Sounds = Diminished, inspiratory stridor Physical Appearance = Age 6 months - 5 yrs, alert with some accessory muscle usage Vital Signs = Increased HR, BP, Qt, low grade temp Past medical history - LBT - CORRECT ANSWER recent cold that developed gradually into a barking cough over 2-3 days, most common in the fall and winter Cough - LBT - CORRECT ANSWER Barking, hoarse voice Appearance of chest - LBT - CORRECT ANSWER Use of accessory muscles during inspiration, substernal and intercostal retractions Respiratory Pattern - LBT - CORRECT ANSWER Tachypnea Color - LBT - CORRECT ANSWER Cyanosis Breath Sounds - LBT - CORRECT ANSWER Diminished, inspiratory stridor Physical Appearance - LBT - CORRECT ANSWER Age 6 months - 5 yrs, alert with some accessory muscle usage Vital Signs - LBT - CORRECT ANSWER Inreased HR, BT, Qt, low grade temp Secondary Assessment - LBT - CORRECT ANSWER Lateral Neck x-ray = Haziness in the subglottic area (below the glottis), steeple sign, pencil point, picket fence, hour glass narrowing of the upper airway ABG = Acute alveolar hyperventilation with hypoxemia Treatment for LBT (mild cases) - CORRECT ANSWER Supportive care -Temp control -cool enviornment -Adequate hydration and humidification of inspired air -Closely monitor : vital signs, Degree of retractions, mental status, ventilatory and oxygenation status -O2 therapy 30-40% -Cool aerosol mist (face mask) -Drug therapy : Racemic epi, corticorsteriods - for pts who do not respond to cool aerosol and recemic epi therapy Treatment for LBT (severe cases) - CORRECT ANSWER Child with severe respiratory distress and/or marked inspiratory stridor Criteria or intubation: -Lethargic -Severe stridor at rest -Diminished breath sounds -extreme accessory muscle usage Temp control - cool environment Adequate hydration and humidification of inspired air Transfer pt to ICU Sedate if necessary Place on T-Piece or CPAP Criteria for extubation - Child's condition is stable -Air leak around the tube (swelling has gone down) Epiglottis - CORRECT ANSWER Life threatening emergency caused by inflammation of the supraglottic region that includes the epiglottis, aryepiglottic folds, and false vocal cords that causes swelling just above the vocal cords Etiology of epiglottis - CORRECT ANSWER Bacterial infection caused by Haemophilius influenza B (gram negative bacteria) transmitted by aerosol droplets Primary Pt Assessment - Epiglottis - CORRECT ANSWER Past Medical History = Sudden onset with 6-8 hrs Cough = Muffled cough Appearance of the Chest = Substernal and intercostal retractions Respiratory Pattern = Tachypnea Color = Pale or Cyanosis Breath Sounds = Diminished, inspiratory stridor Physical Appearance = 2-6 yrs of age, lifeless, drooling, hoarseness, inspiratory stridor, difficulty swallowing, tongue thrusts forward during inspiration, voice and cry muffled, jaw jutted forward Vital Signs = High fever (measured axillary or tympanic to avoid stimulating the child), increased HR, BP, Qt Avoid any unnecessary stimulation of the child Diagnosis should be made at the bedside Past medical history - Epiglottis - CORRECT ANSWER Sudden onset within 6-8 hrs Cough - Epiglottis - CORRECT ANSWER Muffled cough Appearance of chest - Epiglottis - CORRECT ANSWER Substernal and intercostal retractions Respiratory Pattern - Epiglottis - CORRECT ANSWER Tachypnea Color - Epiglottis - CORRECT ANSWER Pale or cyanotic Breath Sounds - Epiglottis - CORRECT ANSWER Diminished, inspiratory stridor Physical Appearance - Epiglottis - CORRECT ANSWER 2-6 yrs of age, lifeless, drooling, hoarseness, inspiratory stridor, dysphagia, tongue thrusts forward during inspiration, voice and cry muffled, jaw jutted forward Vital signs - Epiglottis - CORRECT ANSWER High fever, increased HR, BP, Qt Secondary Assessment - Epiglottis - CORRECT ANSWER Lateral x-ray = Haziness in the supraglottic area, supraglottic swelling, or "thumb sign" ABG= Acute alveolar hyperventilation with hypoxemia CBC = Elevated WBC Lateral Neck x-ray - Epiglottis - CORRECT ANSWER Thumb sign, Haziness in the supraglottic are, or supraglottic swelling ABG -Epiglottis - CORRECT ANSWER Acute alveolar hyperventilation with hypoxemia CBC - Epiglottis - CORRECT ANSWER WBC increased Treatment for Epiglottis - CORRECT ANSWER Immediate placement of an artificial airway ET tube Trach if unable to intubate Transfer pt to ICU Sedate if necessary Place on T-Piece or CPAP Oxygen therapy Drug therapy Antibiotics Criteria for extubation: Child's condition is stable Swelling in the airway has diminished Cystic Fibrosis - CORRECT ANSWER An inherited, genetic disorder involving the exocrine glands The pathologic changes include: -thick viscous mucus accumulation in the lungs -blocked passageways in the pancreas -digestive enzymes are prohibited from reaching the intestines, leading to inhibition of digestion of proteins and fats -deficiencies of vitamins A, D, E, and K Etiology of CF - CORRECT ANSWER -caused by a mutation in a pair of genes loacted on chromosome 7 -Results in dysfunction of the cystic fibrosis transmembrane conductance regulator -This leads to abnormal electrolyte and water movement in and out of the epithelial cells including the : bronchial airways, intestines, pancreas, liver ducts, sweat glands, vas deferens. Bedside assessment for CF - CORRECT ANSWER Past Medical History = Family history of CF, meconium ileus as newborn, recurrent respiratory infections Shortness of Breath = Dyspnea on exertion Cough = Large amount of thick, purulent secretions Respiratory Pattern = Tachypnea, pursed lip breathing, use of accessory muscles of inspiration and expiration Color = Cyanosis Diagnostic Chest Percussion = Hyperresonant or typmanic note Breath Sounds = Diminished, crackles, wheezing Physical Appearance = Small for age, malnutrition, poor body development, barrel chest, clubbing, peripheral edema Vital signs = Increased pulse, BP, and Qt Past Medical History - CF - CORRECT ANSWER Family history of CF, meconium ileus as newborn, recurrent respiratory infections Shortness of Breath - CF - CORRECT ANSWER Dyspnea on exertion Cough - CF - CORRECT ANSWER Large amount of thick, purulent secretions Respiratory Pattern - CF - CORRECT ANSWER Tachypnea, pursed lip breathing, use of accessory muscles of inspiration and expiration Color - CF - CORRECT ANSWER Cyanosis Diagnostic Chest Percussion - CF - CORRECT ANSWER Hyperresonant or typmanic note Breath Sounds - CF - CORRECT ANSWER Diminished, crackles, wheezing Physical Appearance - CF - CORRECT ANSWER Small for age, malnutrition, poor body development, barrel chest, clubbing, peripheral edema Vital Signs - CF - CORRECT ANSWER Increased pulse, BP and Qt Secondary Assessment - CF - CORRECT ANSWER Chest xray = Translucent lung fields, depressed or flattened diaphragm, right ventricular enlargement, areas of atelectasis and fibrosis ABG = Acute alveolar hyperventilation with hypoxemia Pulmonary Function = Decrease flowrates CBC = Elevated Hb and Hct Sputum Culture = Commonly yields Staphylococcus aureus, Haemophilus influenzae, Pseudomonas Special Tests = Sweat chloride test, CFTR gene analysis, immunoreactive trypsinogen test Treatment for CF - CORRECT ANSWER Airway clearance four times daily Chest percussion and postural drainage Exercise PEP therapy High frequency chest wall compression Forced expiratory techniques Active cycle breathing Autogenic drainage Huff Coughing O2 therapy Drug therapy Aerosol: Bronchodilator Mucolytics Anti-inflammatory Inhaled antibiotics: TOBI Colstin Amikan Digestive enzyme replacements Bronchiolitis - CORRECT ANSWER Acute infection of the lower respiratory tract, usually caused by the respiratory syncytial virus (RSV). Results in inflammation and obstruction of the small bronchi and bronchioles. Etiology of bronchiolitis - CORRECT ANSWER RSV most common viral respiratory pathogen in infants and young children Transmitted by young children infected with the virus Highest risk for severe bronchilolitis is in premature infants, children less than 1 yr of age and children with weakened immune systems Primary pt assessment for bronchiolitis - CORRECT ANSWER Past medical history = Upper resp infection in a cild age 3 months to 3 yrs Cough = Intermittent Appearance of chest= Intercostal and substernal retractions Respiratory Pattern = Tachypnea, apnea in severe cases Breath Sounds = Wheezes, rhonchi, crackles Physical Appearance = Nasal discharge, lethargic, nasal flaring, cyanosis Vital Signs = Tachycardia, low grade fever, elevated BP Secondary Assessment - Bronchiolitis - CORRECT ANSWER Chest x-ray = Hyperinflation with areas of consolidation ABG = Acute alveolar hyperventilation with hypoxemia Special Test for Bronchiolitis - CORRECT ANSWER Antigen Assay test conducted on swabs from oropharynx or nasopharynx Treatment for Bronchiolitis - CORRECT ANSWER Prophylaxis recommended for infants : - Less than 2 yrs of age who require therapy for chronic lung disease - Born at less than 32 weeks gestation - With congenital heart disease with cardiovascular compromise - With weakened immune system Drug therapy - Antibodies against RSV Respiratory syncytial virus immune globulin Palivizumab Most cases are treated at home with humidification and oral decongestants Severe cases (for children and severe respiratory distress and/or apnea) require hospitalization and treatment is directed at relieving the airway obstruction and hypxemia by utilizing - Systemic hydration - O2 therapy - Bronchodilator - Airway clearance - Mechanical ventilation for impending or acut vent failure Use slower RR with long expiratory time Foreign Body Obstruction - CORRECT ANSWER Sudden onset of airway obstruction caused by aspiration of a foreign object Etiology of Foreign Body Obstruction - CORRECT ANSWER Highest incidence is among children between 6 months and 3 yrs of age from attempting to ingest a foreign object. A major cause of death in the home. Primary Assessment for Foreign Body Obstruction - CORRECT ANSWER Past Medical History = Sudden onset, survey scene for pieces of food, missing objects, ect Shortness of breath = Dyspnea Cough = Violent Respiratory Pattern = Retractions, tachypnea Color = May by cyanotic Breath Sounds = Varies : Absent, Rhonchi, wheezing, May be unilateral Physical Appearance = Restless Secondary Assessment Foreign Body Obstruction - CORRECT ANSWER Chest x-ray = Inspiratory and expiratory films indicate air trapping, hyperinflation and unequal ventilation Majority of items aspirated are radiolucent and cannot be seen on a chest film (ex food) Delivery Room Care - CORRECT ANSWER Assessment and stabilization of the neonate immediately following delivery Primary Assessment of Delivery Room care - CORRECT ANSWER -Clear airway first with bulb syringe -Dry infant and keep warm -APGAR score - performed 1 min and 5 mins after delivery APGAR score - CORRECT ANSWER Appearance (color) - Good 2 = Completely pink Bad 1 = Body pink extremities blue Real Bad 0 = Blue all over, Pale ____________________________________________________________ Pulse - Good 2 = 100 Bad 1 = 100 Real Bad 0 = Absent _____________________________________________________________ Grimace - Good 2 = Cough or sneeze Bad 1 = Grimace Real Bad 0 = No response ______________________________________________________________ Activity - Good 2 = Active motion Bad 1 = Some flexion of extremities Real Bad 0 =Limp, no movement ________________________________________________________________ Respiratory effort - Good 2 = Regular, strong cry Bad = Slow, irregular or weak cry Real Bad = Absent, No cry Secondary Assessment Delivery Room Care - CORRECT ANSWER As neonates condition allows, evaluate: - History - family, mother, pregnancy, delivery - Gestational age - Birthweight - General Appearance - color, chest configuration - Breath Sounds Treatment - CORRECT ANSWER Action based on APGAR score Score 0-3 Resuscitate (CPR) Score 4-6 Stimulate, warm, administer O2, assist ventilation Score 7-10 Monitor, provide routine care Apnea of Prematurity - CORRECT ANSWER Apnea caused by immature neurologic control of ventilation Etiology of Apnea of Prematurity - CORRECT ANSWER Immature CNS Primary Assessment of Apnea of Prematurity - CORRECT ANSWER Past medical history = Premature, episodes of central apnea Respiratory Pattern = Periodic apnea, irregular breathing Color = Periodic cyanotic spells Vital Signs = Periods of bradycardia, variations in thermal regulation Secondary Assessment Apnea of Prematurity - CORRECT ANSWER Basic Laboratory Tests = Help rule out other causes Special Tests = Polysomnogram Treatment Apnea of Prematurity - CORRECT ANSWER O2 therapy - 30-50 % as indicated by oximetry Methylanthines (caffeine) Mechanical ventilation if necessary Teach parents/family CPR Send infant home with an apnea monitor Meconium Aspiration Syndrome - CORRECT ANSWER Condition in which a fetus aspirates a mix of fetal stool and amniotic fluid during episodes of fetal hypoxemia Etiology of Meconium Aspiration Syndrome - CORRECT ANSWER Occurs in 8-15% of all births Occurs in full-term or post-term infants Cannot be prevented even with the best maternal care Primary Assessment of Meconium Aspiration Syndrome - CORRECT ANSWER Past Medical History = More common in post term infants ( more than 42 wks) Respiration Pattern = Grunting, substernal retractions/abdominal distension (seesaw movement), nasal flaring, asphyxia, gasping w/ tachypnea, apnea Color = Cyanosis Breath Sounds = Wheezes, rhonchi, crackles Physical Appearance = Low APGAR scores, stained with meconium Heart Rate = Tachycardia, elevated BP Secondary Assessment of Meconium Aspiration Syndrome - CORRECT ANSWER Chest x-ray = Irregular densities throughout the lungs with atelectasis and consolidation ABG = Acute alveolar hyperventilation with hypoxemia Treatment for Meconium Aspiration Syndrome - CORRECT ANSWER Suction the nasopharynx and oropharynx thoroughly when amniotic fluid is stained Follow NRP guidlines -If the infant is vigorous, active and crying (Pulse 100, strong respirations, good muscle tone 1. suction mouth and nose to clear pharynx 2. Warm, dry and observe 3. Blow-by o2 as needed -If infant is not vigorous (Pulse 100, limp, depressed, poor tone, absent or grasping respiration): 1. No PPV 2. Visualize vocal cords with a laryngoscope 3. Intubate with a meconium aspirator and suction trachea 4. Repeat until the airway is clear - even if HR is low 5. Intubate and provide airway -Stabilize infant and transfer to ICU 1. Vigorous pulmonary hygiene 2. O2 therapy 3. Mechanical Ventilation for vent failure 4. Drug therapy : antibiotics, steroids Congenital Heart Defects - CORRECT ANSWER Structural abnormality of the heart present at birth Etiology Congenital Heart Defects - CORRECT ANSWER Cyanotic : Right to left shunt (Severe hypoxemia0 -Tetralogy of Fallot -Transpostion of the great vessels Acyanotic : - Atrial septal defect - Ventricular septal defect -Patent ductus arterious Primary Pt Assessment Congenital Heart Defects - CORRECT ANSWER Color = Cyanosis Auscultation = Normal Breath Sounds, heart murmur Physical Appearance = Respiratory distress Secondary Assessment Congenital Heart Defects - CORRECT ANSWER Chest x-ray = possibly an enlarged or abnormal shaped heart -Egg-Shaped heart with Transposition of the great vessels -Boot shaped heart with Tetralogy of fallout Echocardiogram is the most important diagnostic test to identify cardiac defects: -Tetraology of fallot - overriding aorta, pulmonary stenosis, ventricular septal defect, and right ventricular hypertrophy -Transposition of the great vessels - aorta switched with pulmonary artery -Patent Ductus Ateriosis (PDA) - failure of the ductus arteriosis to close. Most often results in a left to right shunt. Treatment for Congenital Heart Defects - CORRECT ANSWER O2 therapy - maintain PaO2 levels between 50-80 torr Mechanical ventilation for ventilatory failure Supportive care prior to surgery to correct the defect Prostaglandin E1 may be helpful to maintain a PDA IRDS - CORRECT ANSWER Also called RDS and hyaline membrane disease. Primarily associated with prematurity or high risk infants Etiology of IRDS - CORRECT ANSWER Caused by insufficient amount of pulmonary surfactant or depressed surfactant activity that leads to massive atelectasis and hypoxemia Primary Assessment for IRDS - CORRECT ANSWER Past medical history= Gestational age 38 wks, low APGAR scores, onset of present at birth or within a few hrs after delivery, L/S ratio 2:1 Appearance of chest = intercostal retractions Resp Pattern = Tachypnea and possible apnea Color = Cyanosis Breath Sounds = Bronchial or harsh, fine crackles/rales, expiratory grunting Physical Appearance = Nasal flaring, grunting, retractions Vital Signs = Increased HR, BP, Qt Secondary Assessment for IRDS - CORRECT ANSWER Chest x-ray = increased opacity, ground glass appearance, air bronchograms ABG = Acute alveolar hyperventilation with hypoxemia Treatment for IRDS - CORRECT ANSWER Correct hypoxemia -Oxygen via oxyhood or nasal cannula - CPAP ( 4-6 cmH2O) -Maintain PaO2 between 50-80 torr and SpO2 between 89-90% Maintain neutral environment Surfactant replacement therapy: -Administered immediately after birth in neonates 35 wks, or once IRDS has been diagnosed -Instill directly into the trachea through a 5 FR catheter placed into the ET tube -Administered in 4 portions one at a time - Catheter is removed after each administration -Infant is manually ventilated for 30 secs -Change pt position to increase distribution of surfactant in the lungs -Observe for adverse reactions Mechanical ventilation with PEEP for vent failure Asthma - CORRECT ANSWER A chronic infalmmatory, obstructive, non contagious airway disease with varying levels of severity, characterized by increased responsiveness of the small airways to stimuli -episodes occur when the pt is exposed to a specific trigger, such as dust, grass, pollen, smoke, ect Etiology of Asthma - CORRECT ANSWER -external environmental agents (triggers) -Infections -Exercise -Cold air exposure -Chemical exposure -GERD -Sleep -Emotional stress -PMS Primary Assessment of Asthma - CORRECT ANSWER Past Medical History = Allergies, episodes of cough, and wheezing Pursed lip breathing, chest tightness Cough = Increased and productive with presence of eosinophils Appearance of Chest = Increased A-P diameter during episode Respiratory Pattern = Accessory muscle usage, tachypnea Color = Cyanotic Diagnostic Chest Percussion = Hyperresonant/tympanic note Breath Sounds = Diffuse wheezing, diminished breath sounds Physical Appearance = Diaphoresis, anxious, speaking only in short phrases Vital Signs = Tachycardia, pulsus paradoxus during severe episodes Secondary Assessment of Asthma - CORRECT ANSWER Chest x-ray = During acute episode: increased A-P diameter, translucent lung fields, depressed or flattened diaphragms ABG= initially acute alveolar hyperventilation with hpoxemia, may develop hypercabia in status asthmaticus Pulmonary Function = Decreased flowrates, Normal DLco, Post bronchodilator - significant improvement if FEV1 increases at least 12% and 200ml Treatment for Asthma - CORRECT ANSWER ED treatment for acute episodes should include -o2 therapy -aerosol therapy with a SABA and anticholinergic -corticorsteriods -Close monitoring (PEFR) -Intuabtion and mechanical ventilation if resp arrest occurs -Consider adjunct therapies: heliox therapy, magnesium sulfate, subcutaneous epi Long term Control of Asthma -Bronchodilators (SABA, LABA, anticholinergic) -Corticorsteriods -Asthma action plan based on peak flow monitoring -Bronchoplumonary hygiene -Environmental control Asthma triggers should be eliminated, minimized, or avoided to prevent acute attacks -Common triggers include pet dander, smoke/fumes, pollen, molds, mites, cockroaches, and certain foods To control triggers, be sure to: -keep the home as clean as possibel -Use filters on vacuum cleaners and heating systems -Keep windows closed -Keep pets outside or out of pts bedroom -Minimize carpeting and upholstered furniture -Use bleach to control mold -Control cockroaches Exposure/Accidental Hypothermia - CORRECT ANSWER Marked cooling of core tempeature (below 35 C - 95F) Eitology of Exposure/Accidental Hypothermia - CORRECT ANSWER Generally the result of sudden immersion in cold water, prolonged exposure to cold environments, person with inadequate clothing, shelter, or heat Primary Assessment - Exposure/Accidental Hypothermia - CORRECT ANSWER Past Medical History = History of near drowning or cold exposure, indigent, homeless or elderly persons Physical Appearance = Shivering, confused, poor coordination, cyanosis, peripheral vasoconstriction Vital Signs = Decreased HR, RR, Qt, temperature Secondary Assessment - Exposure/Accidental Hypothermia - CORRECT ANSWER ABG = Moderate to severe acidosis with hypoxemia Pneumonia/Infectious Disease - CORRECT ANSWER An infectious inflammatory process that primarily affects the gas exchange areas of the lung causing capillary fluid (serum) to out into the alveoli. This process leads to inflammation of the alveoli, alveolar consolidation, and atelectasis. Etiology of Pneumonia/Infectious Disease - CORRECT ANSWER -Extremely common -Causes include: bacteria, viruses, and aspiration Primary Assessment for Pneumonia/Infectious Disease - CORRECT ANSWER Past Medical History = Initially mimics a cold or flu, signs and symptoms may develop quickly, may have chest pain Shortness of breath = may be present Cough = Productive, yellow/green sputum Chest findings = Decreased expansion, increased tactile and vocal fremitus Respiratory Pattern = Tachypnea Color = Cyanosis Diagnostic Chest Percussion = Flat or dull note Breath Sounds = Crackles, bronchial, whispered pectoriloquy