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NR 602 Quiz 3 Study Guide
Respiratory Infections
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Leading cause of morbidity and mortality in children
Respiratory failure can develop rapidly with ominous symptoms
Be able to recognize key respiratory sounds
o Croup cough vs. other coughs *Sound bit croup cough: see link under Croup*
o Inspiratory stridor *Sound bit: (https://www.easyauscultation.com/heart-lung-soundsdetails/140/Stridor)
o Wheezing * Sound bit: (https://www.easyauscultation.com/heart-lung-sounds-details/71/Wheeze)
Critical Sign: Tachypnea!
o Respiratory Rates:
 Infants (birth to 12 months): 30-53 bpm (RR > 60 requires further evaluation)
 Toddlers (1-2 yrs): 22-37 bpm (RR > 40 requires further evaluation)
 Preschool (3-5 yrs): 20-28 bpm
 School Age (6-9 yrs): 18-25 bpm
 Pre-Adolescent (10-11 yrs): 18-25 bpm
 Adolescent (12yrs and older): 12-20 bpm
o Red Flags: Tachypnea +
 grunting,
 nasal flaring,
 use of accessory muscles
Upper Respiratory Infections are the most common (common cold)
o Most often Viral
 Rhinovirus, Parainfluenza, RSV, Coronavirus, human metapneumovirus
 Self-limiting lasting 7-10days
o Peak: Spring and Winter
o Common Sxs: (gradual onset)
 Low grade fever
 Nasal Congestion
 Sore throat, hoarseness
 *Hallmark: Rhinorrhea (clear at first, progresses to purulent)
 Cough/Sneezing
o Clinical Findings:
 Conjunctiva: mild injection
 Erythematous nasal mucosa with mucus
 Erythematous posterior oropharynx
 Anterior cervical lymphadenopathy
Diagnostics:
o ONLY if in doubt of URI: sore throat without drainage or cough
 Rapid antigen detection test (RADT): rapid strep
 Throat culture if RADT negative
o Treatment: Supportive Care
 Hydration
 OTC antipyretics as directed (weight dose)
 Normal saline nasal rinse
 Topical menthol
 NO Antibiotics prophylactically
o Complications: secondary infection
 Bacterial infection
 Otitis media
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 Sinusitis
 Asthma exacerbation
Pharyngitis, Tonsillitis, and Tonsillopharyngitis
o Inflammation of mucosal lining of the throat structures
o Infectious or noninfectious causes
 Viral or bacterial
 Viral (most common): adenovirus (pharyngitis primary sx), Epstein-Barr (EBV),
herpes simplex (HSV), cytomegalovirus (CMV), enterovirus, parainfluenza,
HIV
o Upper nasal symptoms, cough and rhinorrhea, hoarseness,
conjunctivitis, rash, diarrhea
o Occur year round, except adenovirus which is predominantly summer
(contaminated swimming pools)
 Bacterial: GABHS (most common in 5-13 year olds), gonococcal (15-19 year
olds), Corynebacterium diphtheria (RARE), Arcanobacterium haemolyticum,
Neisseria gonorrheae(adolescents), Chlamydia trachomatis (adolescents),
Francisella tularensis, Mycoplasma pneumonia, Group C & G Strep
o GABHS: typically late winter and early spring
o Acute abrupt onset: sore throat, headache, nausea, vomiting, abdominal
pain, myalgia, arthralgia, malaise
 Respiratory irritants (smoke)
o Clinical Findings:
 Erythematous tonsils and pharynx
 EBV: exudates on tonsils, petechiae on soft palate, diffuse adenopathy
 Adenovirus: follicular pattern on pharynx
 Enterovirus: vesicles or ulcers on tonsillar pillars, coryza, vomiting, diarrhea
 Herpes: anterior ulcers, adenopathy
 Parainfluenza and RSV: lower respiratory sx, stridor, rales, and wheezing
 Influenza: cough, fever, systemic sxs
 M. pneumo & Chlamydophila pneumo: cough, pharyngitis
 GABHS: exudative Erythematous pharyngitis with follicular pattern without presence of
cough or nasal symptoms, swollen beefy red uvula, enlarged tonsillopharyngeal tissue,
anterior cervical lymphadenopathy, bad breath, scarlatiniform rash, strawberry tongue
 A. haemolyticum: exudative pharyngitis, marked erythema and pruritic, fine
scarlatiniform rash
o Diagnostics:
 RADT and/or throat culture if >3 years old with pharyngitis or if someone in household
is + Strep
 Culture if RADT negative, or suspect A. haemolyticum, N. gonorrhea or C. diphtheria
 If suspect Mononucleosis: CBC
o Treatment:
 Supportive care: ibuprofen, acetaminophen
 Hydration
 GABHS with + RADT or + culture: antibiotics
 PCN V potassium – 1st choice
 Amoxicillin suspension
 Benzathine pcn G IM
 Allergy to PCN:
o Cephalexin
o Cefadroxil
o Clindamycin (1st choice if chronic symptomatic carriage of GABHS)
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o Azithromycin
o clarithromycin
If CMV or EBV: beta-lactam antibiotic causes diffuse morbilliform skin eruption
Discard/Clean: bathroom cups, toothbrush, orthodontic devices
Return to school when afebrile or on antibiotic for 24 hours
Tonsillectomy/adenoidectomy:
 if > 7 throat infections in past year, >5 throat infections in past 2 years, >3
throat infections per year x 3 years
 sleep apnea
 adenoid hypertrophy
 unresponsive rhinosinusitis
 chronic otitis media (post tympanostomy tube placement)
Sinusitis/Rhinosinusitis
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URI lasting 10 to 14 days with no symptoms improvement or worsening symptoms
o Acute (ARS): lasting as long as 4 weeks
o Chronic (CRS): persist 12 weeks or more
Inflammation and edema of mucous membranes lining the sinuses
Bacterial: Strep pneumo., H. influenza, Moraxella catarrhalis, Staph. Aureus (less often)
Risk factors:
o Preceding infection
o Environmental irritants/allergies
o Anatomic problems (septal deviation, nasal polyps, facial trauma)
o GERD
o CF, ciliary dyskinesia
o Immunodeficiency
Clinical Findings:
o Thick, yellow discharge
o Worsening symptoms after initial improvement from URI
o Sx: headache, fatigue, decreased appetite
o Bad breath (halitosis)
o Facial pain*
o Facial/nasal congestion and fullness*
o Purulent postnasal drainage and nasal discharge
o Cough
o Ear pain/fullness/pressure
Treatment:
o Watchful waiting: do not over use antibiotics
 Symptom management: ibuprofen, acetaminophen
 Rest
 Reassess after 72 hours
o Chronic: referral to ENT
o Antibiotics Criteria per AAP Guidelines:
 URI with persistent nasal discharge, daytime cough, lasting >10 days without
improvement
 URI with worsening symptoms, new onset of fever, nasal discharge, or daytime cough
after initial improvement
 Fever > 102.2 F (39 C) with purulent nasal discharge for at least 3 days and sinusitis
 Amoxicillin – 1st line x10-28 days or 7 days past symptom resolution
 45 mg/kg divided into 2 doses/day
 S. pneumo: 80-90 mg/kg/day (max: 1000 mg/dose)
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Child < 2 yrs, daycare attendee, recent antibiotic use, or severe illness: Augmentin 80-90
mg/kg/day of amoxicillin part (max: 2 grams/dose)
Vomiting: ceftriaxone 50 mg/kg IV or IM
PCN allergy type I: 3rd generation cephalosporin (cefdinir, cefpodoxime, cefuroxime)
Bronchitis/ Bronchiolitis/ Respiratory Syncytial Virus (RSV)
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inflammatory process of the bronchus, or bronchioles (small airways)
most commonly caused by a Virus
o MOST Common: Respiratory Syncytial Virus (RSV)
o Others: influenza, parainfluenza, adenovirus, enterovirus, bocavirus, and rhinovirus
o Rarely: can have rare bacterial cause: Mycoplasma pneumonia
Highly CONTAGIOUS
Direct Contact and Droplet Transmission
o Incubation period before symptoms start
High Risk: children with
o Prematurity
o Chronic lung disease
o Immunocompromised
o Participating in Day Care
Symptoms:
o Starts as URI
o Worsening cough
o Rhinorrhea
o *HALLMARK: Wheezing
Exam Findings:
o Increased work of breathing
o Prolonged expiration
o Intercostals retraction
o Grunting
o Nasal flaring
o Wheezes and crackles *Sound bit: polyphonic wheeze found in RSV:
(https://www.easyauscultation.com/heart-lung-sounds-details/144/Wheeze-Polyphonic), crackles
(https://www.easyauscultation.com/heart-lung-sounds-details/72/Crackles-Fine-(Rales))
o Abdominal distention, palpable liver and spleen
o Chest X-ray (not typically done): hyperinflation, atelectasis, flattening diaphragm
Complications: may progress to
o Pneumonia
o Respiratory distress and hypoxia
o Respiratory acidosis
Treatment:
o Supportive Care
 Monitory pulse oximetry and respiratory status
 Supplemental Oxygen
 Hydration (oral, NG, IV)
 Nutrition
 Suction
o Hospitalization
 Age < 2 months
 Respiratory distress
 Progressive stridor or stridor at rest
 Apnea
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RR > 50-60 bpm (sleeping)
Cyanosis, hypoxia
Inability to tolerate oral feeding
Depressed sensorium
Presence of chronic cardiovascular or immunodeficiency disease
Pertussis “Whooping Cough”
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Gram-negative bacillus: Bordetella pertussis
Hallmark: high-pitched inspiratory whoop follows by spasms of coughing *Sound bit:
(https://www.youtube.com/watch?v=zuK4honWVsE)
Aerosol droplet transmission
7-10 day incubation, most contagious during first 2 weeks
Cough lasts 6-10 weeks (possibly longer in adolescents)
Vaccination: DTaP or Tdap
Symptoms:
o Most severe in infants < 6 months
 Apnea
 Seizures induced by hypoxemia
 Cough without inspiratory whoop
 Tachypnea
 Poor feeding
 Leukocytosis nad lymphocytosis
Diagnostics:
o Gold standard: culture with Dacron or Calcium alginate swab of nasopharynx (only 12%-60%
specific)
o PCR (improved sensitivity)
Treatment:
o Macrolide (not in infants < 1 month due to pyloric stenosis)
 Azithromycin – 1st line
 Clarithromycin
 Erythromycin
o Macrolide allergy: Bactrim
o Chemoprophylaxis in household and close contact exposure: monitor x 21 days
Prevention
o “Cocooning”: vaccination of all adults and relatives close to infant and protection from
environmental hazards
o Vaccinate
Pneumonia
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Bacterial or Viral
o Bacterial:
 less common in childhood
 S. pneumo.
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Most common cause
 Lobar pneumonia
 Methicillin resistant Staph aureus(MRSA)
 Community acquired
 Empyema
 Necrosis
o Viral:
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 More common in children < 2 yrs
 Gradual onset
Typical or Atypical
o Typical: lobar, infection of alveolar space resulting in consolidation
o Atypical: non-localized consolidation
 Walking pneumonia
Risk factors: neonates
o Prolonged rupture of membranes
o Maternal amnionitis
o Premature delivery
o Fetal tachycardia
o Maternal intrapartum fever
o Airway anomaly
Symptoms (vary by age group):
o Neonates:
 *Fever,
 irritability,
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lethargy
o Older Children:
 *Cough
 *Fever
 Tachypnea, tachycardia, air-hunger
 Downward displacement of liver and spleen
 Obvious illness (lethargy, decreased appetite, look unwell)
o C. trachomatis: repetitive staccato cough with tachypnea, cervical adenopathy, and crackles
Treatment:
o If sxs not improving after 72 hours: Chest x-ray
o Neonates: admit to hospital
o Supportive care:
 Antipyretics
 Hydration
 Rest
o Antibiotics: by age and causative organism
 Chlamydia: azithromycin or amoxicillin, erythromycin, ethyl succinate
 C.pneumo, M. pneumo: azithromycin, macrolide+ beta-lactam
 S. pneumo: 3rd generation cephalosporin
 S. aureus: vancomycin, clindamycin + beta-lactam
Complications:
o Respiratory Distress, pneumothorax
o Meningitis
o CNS abscess
o Endocarditis, pericarditis
o Osteomyelitis, septic arthritis
Vaccination: Prevnar 13
Rotavirus
Croup
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Viral infection of the middle respiratory track (Larynx and bronchial tree
Laryngotraceitis / Laryngotracheobronchitis (LTB)
o Viral: parainfluenza type 1 & 2 (HPIV)
o LTB more severe, occurs 5 – 7 days in to the disease
Usually children < 6 yrs
Season: fall and winter
Incubation period: 2-4 days with viral shedding up to 1 week, lasts approx. 5 days
HALLMARK: Barking Cough *Sound bit: 1, 2, 3 (https://mommyhood101.com/croup-audio-clips
Diagnosis: made by symptoms/clinical presentation
Symptoms:
o Low grade fever
o URI symptoms- gradual onset (rhinorrhea, congestion)
o Barking Cough
o Hoarseness
o Dyspnea
o Respiratory Distress (Intercostal retraction, tachypnea, cyanosis, accessory muscles, nasal flaring)
Clinical Findings:
o Tachypnea
o Prolonged inspiration
o Inspiratory stridor (as airway obstruction worsens) *Sound bit: 4, 5
(https://mommyhood101.com/croup-audio-clips)
o Wheezing (if lower airway involved)
o Chest X-Ray (not typically done): subglottic narrowing – Steeple Sign
Treatment:
o Supportive Care: Symptom Management
 Cold air
 Hydration
o Glucocorticoids: reduce airway swelling
 Dexamethasone 0.6 mg/kg to1 mg/kg IM PO
o Aerosolized racemic epinephrine: reduce swelling of larynx and subglottis
o Bronchodilator
o Hospitalization:
 RR > 70 bpm
 Stridor at rest
 Temperature > 102.2 F (39C)
Complications:
o Pneumonia
o Respiratory distress
Epiglottitis
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Inflammation of epiglottis, aryepiglottic folds, and ventricular bands at the base of the epiglottis
Cause: H. influenza type B (HiB)
Prevention: HiB vaccine
Typically age 1-5 yrs (most under 2 yrs)
Symptoms:
o Abrupt onset fever
o Severe sore throat
o Dyspnea
o Inspiratory distress without stridor
o *drooling
o Toxic look
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Clinical Findings: Emergent- Death within hours
o * If epiglottitis is suspected: do NOT examine throat, do NOT place in supine position,
Immediately transfer to ER
o Expiratory stridor
o Drooling
o Aphonia (muffled, ‘hot potatoe’ voice)
o Rapid progression of respiratory obstruction
o High fever
o Flaring ala nasi and retraction of supraclavicular, intercostals, and subcostal spaces
o Hyperextension of the neck
Diagnostic:
o Blood culture
o Lateral neck radiograph: absence of ‘thumb’ sign rules out condition
o Confirmed in OR
Treatment:
o Establish airway (possible intubation or tracheostomy)
o Start antimicrobials IV broad spectrum
 Rifampin prophylaxis to all household members (20 mg/kg, max: 600 mg, x 4 days)
o O2/ respiratory support
Foreign Body Occlusion/ Aspiration
Nasal Occlusion
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Symptoms:
o Recurrent, unilateral purulent nasal discharge
o Foul odor
o Epistaxis
o Nasal obstruction/ mouth breathing
Detection of FB in nasal passageway
Removal:
o Alligator forceps
o Suction with narrow tips
o Cotton tipped applicators w/ or w/o topical vasoconstrictor
o Hook or curette
o 5-Fr catheter balloon inflation behind FB
o Refer to ENT
Laryngeal FB Aspiration
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Symptoms:
o Rapid onset hoarseness
o Croupy cough
o Aphonia
Tracheal FB Aspiration
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Symptoms:
o Brassy cough
o Hoarseness
o dyspnea
Bronchial FB Aspiration
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Symptoms:
o Unilateral wheeze, usually aspirated into *Right lung
o Recurrent pneumonia
o HX of Choking episode
Clinical Findings:
o Cyanosis
o Hemoptysis, blood streaked sputum
o Decreased vocal fremitus
o Limited chest expansion
o Diminished breath sounds
o Unilateral wheezes
 Tracheal: homophonic wheeze: wheeze with audible ‘slap’ and palpable ‘thud’ on
expiration
Diagnostic:
o Inspiratory and forced expiratory chest radiographs
o Chest fluoroscopy
Treatment: Referral to Pulmonary Specialist
Complications:
o If vegetable matter: severe condition
 Fever, sepsis-like sxs, dyspnea, cough
o Lobar pneumonia
o Status asthmaticus
o Emphysema, atelectasis
Prevention: Education on high risk foods/objects:
o Carrots, nuts, popcorn, hot dog chunks
o Small toys, coins, buttons, etc
Restrictive Airway Diseases
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Less common in pediatrics
Decreased lung compliance with relatively normal flow rates
HALLMARK: tachypnea and decreased tidal volume/capacity
Causes:
o Neuromuscular weakness
o Lobar pneumonia
o Pleural effusion or mass
o Severe pectus excavatum
o Abdominal distention
Asthma *Know Levels of severity*
Cystic Fibrosis (CF)
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Genetic disorder, autosomal recessive, mutation of CFTR protein on chromosome 7
Multisystem, progressive disease: COPD, GI disturbances, *exocrine dysfunction
Life expectancy: 41 yrs
Symptoms:
o Respiratory: chronic airway inflammation and lung infections, viscous mucus, *mucociliary
transport dysfunction, chronic cough, and *excess sputum production, respiratory failure
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GI: meconium ileus, pancreatic insufficiency, rectal prolapsed, GI obstruction, failure to thrive,
edema, hypoproteinemia, steatorrhea, poor muscle mass, GERD, *vitamin deficiencies (A, K, E,
D)
o Hepatic: biliary cirrhosis, jaundice, ascites, hematemesis, esophageal varices, cholelithiasis
o Endocrine: recurrent acute pancreatitis, CF related diabetes (CFRD)
o Musculoskeletal: osteoporosis
o Reproductive: delayed sexual development, nonfunctional vas deferens (male sterility),
undescended testes, hydrocele, demale decreased fertility, cervicitis
o Sweat: *“taste salty”, hypochloremic alkalosis, dehydration
Diagnostic:
o Newborn screening performed
o Gold Standard: pilocarpine iontophoresis sweat test
 Only ordered if child has more than one clinical feature of CF
 Sweat chloride concentration > 60 mmol/L (age > 6 months), > 30 mmol/L (in infants)
o PFTs
o Glycosylated hemoglobin (elevated)
Treatment: complicated, require multidisciplinary team
o Pulmonary: promote airway clearance
 Inhaled dornase alfa :reduce mucus viscosity
 Hypertonic saline: thins mucus
 Postural drainage (cycle: active breathing, autogenic drainage, percussion, positive
expiratory pressure, exercise, high frequency chest wall oscillation) BID
 High dose Ibuprofen: reduce airway inflammation
 Azithromycin 3x/week (ibuprofen decreases neutrophil mitigation)
 Lung transplant
o GI:
 Pancreatic enzyme supplementation
 Vitamin replacement and serum monitoring (A, D, E, K)
 Osmotic laxatives, Gastrografin enemas
o Endocrine
 Glucose tolerance test
 Diabetes management
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Salmonella
Clostridium difficile
Cryptosporidium
Pyloric Stenosis
Pinworms
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Gastric Esophageal Reflux (GERD)
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Common in young infants: anatomical reasons
o Spitting up after meals
Foreign Body Ingestion
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Common in children exploring their environment with mouths and hands
Common locations:
o Thoracic inlet, pyloris, ileocecal junction
Common Culprits: Coins
o Most pass without problem; 10-20% need surgery
Symptoms:
o Dysphagia
o odynophagia,
o drooling,
o regurgitation,
o abdominal pain,
o difficulty breathing
Urinary Tract Infection
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More common in females > uncircumcised male > circumcised males
o Girls who have > 2 UTIs, urology consult is recommended
o Boys who have >1 UTIs, urology consult is recommended
Lower UTI: uncomplicated, bladder and urethra
Upper UTI: complicated, urethra, bladder, ureters, kidneys
o May require hospitalization
 Fluid stabilization
 Treatment
 Monitoring for sepsis
Risk Factors:
o Perineal irritation (soaps, bubble baths, fragrances, wipes)
o Not wiping front to back
o uncircumcised
Symptoms:
o Infants:
 Fever/hypothermia
 Jaundice
 Poor feeding
 Irritability
 Vomiting
 Strong smelling urine
 Failure to thrive
 Sepsis
o Children:
 Abdominal/ flank pain
 Urinary frequency
 Dysuria
 Urgency
 Enuresis
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Vomiting
Fever
Diagnostics:
o Urinalysis
o Urine culture and sensitivity
o Gram stain
o Hydration status and electrolyte values
Most common cause: E. coli (85%)
o Others: Klebsiella, Proteus, Enterococcus, Staphylococcus, and Streptococcus
Treatment: dependent on culture, child’s age, and clinical guidelines
Primary Enuresis
Glomerulonephritis
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Result of renal insult caused by immunoglobulin damage to the kidney
Red Flag: hematuria
Types:
o Post-infection: most common
 Post-streptococcal infection: occurs 10 to 14 days post-primary infection
 Sx: edema, renal insufficiency
 Dark, tea-colored urine
o Membranoproliferative
o IgA nephropathy
o Henoch – Schonlein purpura (HSP):
 Most common cause of small vessel vasculitis in children 2-7 yrs old
 Sx: itching, urticaria, maculopapular rash with purpura on legs, buttocks, and elbows
 Joint pain
 50% chance of renal involvement
o Systemic lupus
o Alport syndrome
Osgood-Schlatter
Juvenile Rheumatoid Arthirits
Osteomyelitis
Transcient Synovitis of the Hip
Legg-Calve’ – Perthes Disease
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Idiopathic Scoliosis
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How should the APRN teach the parents to manage the child’s symptoms?
Fevers in children under 36 months of age can have potentially serious consequences.
For a 2 month old infant, which tests should the APRN considering ordering?