Category Archives: Medical- Surgical Nursing

Bronchiectasis

Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of COPD, it is considered a disease process separate from COPD (GOLD, 2008).
Bronchiectasis is a condition where the bronchial tubes of your lungs are permanently damaged, widened, and thickened.

Pathophysiology

Bronchiectasis is an obstructive lung condition in which there is destruction and widening of the large airways and abnormal bronchial wall thickening as a result of a recurring cycle of infection and inflammation (Ten Hacken 2010). Bronchiectasis is usually localised to one lung segment or lobe but may spread over time to other parts of the same lung as a result of unresolved infections. Exacerbations are associated with infections.
A number of conditions lead to bronchiectasis, including structural lung conditions, CF and other conditions associated with abnormal mucocillary clearance; retained inhaled foreign objects, tumours and obstructive lung conditions including COPD; an abnormal immune response; infections including tuberculosis, pneumonia, measles and whooping cough; and inflammatory bowel disease.

Clinical manifestations

  • Difficult breathing (dyspnea) due to the mucous production and irritation within the airways.
  • Productive, foul-smelling odorous cough, due to thick, difficult-to-expel, tenacious mucous, often with bacterial colonization.
  • Cough may be worse when lying down.
  • Recurrent bronchial infections.
  • Hemoptysis (blood-tinged or bloody mucous).
  • Loss of weight because patients are not eating well, due to respiratory changes and foul-smelling mucous with cough. Increased respiratory effort requires more calories to meet normal requirements.
  • Crackles or rhonchi on inspiration due to mucous build-up.
  • Anemia of chronic disease.
  • Cyanosis.
  • Clubbing of the fingers.

Causes
Bronchiectasis may be caused by a variety of conditions including:

  • Airway obstruction: Obstructions in the bronchi distend the wall permanently and impair mucociliary action.
  • Pulmonary infection: Pulmonary infection and obstruction of the bronchus or complications of long-term pulmonary infections cause bronchiectasis.
  • Genetic disorders: Genetic disorders such as cystic fibrosis causes the sputum to thicken in consistency and would ultimately obstruct the bronchi.
  • Idiopathic causes: There are causes that are unknown to medicine that cause bronchiectasis.

Complications
Potential complications include:

  • Atelectasi: Collapse of the alveoli is a common complication.
  • Pneumonia: Infection is recurrent in patients with bronchiectasis.
  • Empyema: Overproduction of sputum causes the bronchi to be filled with pus.

Diagnosis

  • Culture and sensitivity of sputum to identify bacteria and appropriate antibiotics.
  • Shadows in affected area of the lungs on the chest x-ray.
  • CT scan or high-resolution CT will show areas of bronchiectasis.
  • Decreased lung vital capacity on pulmonary function test.

TREATMENT
Treatment is focused on getting enough oxygen to meet current needs of the patient, expel mucous, and treat infections.

  • Supplemental oxygen to help meet body’s needs.
  • Postural drainage to assist with drainage of secretions.
  • Chest PT to loosen secretions.
  • Remove excessive secretions during a bronchoscopy.
  • Administer bronchodilators to help keep airways open:
    • albuterol, levalbuterol
  • Administer antibiotics to treat infection:
    • selected based on the results of a culture and sensitivity study

NURSING DIAGNOSES

  • Ineffective airway clearance
  • Imbalanced nutrition: less than what the body requires
  • Impaired gas exchange

NURSING INTERVENTION

  • Monitor respiratory rate, effort, breath sounds, skin color, and use of accessory muscles.
  • Perform chest percussion to help loosen secretions.
  • Explain to the patient:
    • That family member can perform chest PT.
    • How to do postural drainage.
    • How to administer oxygen.
    • How to properly administer medications.

See videos:

Bronchitis  Chronic Bronchitis

Abnormal breath sounds

Breath sounds are an important part of respiratory assessment and are usually assessed by the respiratory team.

Sound Characteristic Signs of
Wheezing Whistling sound, generally heard on

expiration

Asthma and airway obstruction
Stridor Snoring sound heard on inspiration Typical of obstruction, sputum plug or

foreign body, anaphylactic reaction

Crackles A crackling or popping sound Collapsed alveoli popping open on

inspiration

Rhonchi Snoring or rattling sounds Fluid partly blocking the bronchi; generally

heard on expiration

Pleural friction A grating or rubbing sound heard on

inspiration and expiration

Indicative of pleural inflammation

General Respiratory Assessment

 

Focus Observe Normal adult values Abnormalities Indications
Respiration Quality, rate Rate: 12–18 per
minute
Bradypnoea <10
breaths per minute
Head injury
Narcotic overdose
Tachypnoea Following exertion
Pneumonia
Diabetic ketoacidosis
Pyrexia – rate of
breathing increases by
7 breaths per minute
for every 10°C rise in
the patient’s
temperature
Apnoea Respiratory arrest
Depth Shallow or deep Hyperventilation
Hypoventilation
(hypercapnia)
Rhythm Regular rhythm Cluster breathing –
normal breathing
interspersed with
apnoeic pauses
Neurological disorders
Cheyne–Stokes –
the rate changes
with increasing
periods of apnoea
End of life
Effort Unable to complete a sentence
Use of accessory
muscles
Muscle retraction –intercostal and
suprasternal muscles
Nasal flaring
Pneumonia
Airway inflammation/
obstruction
Emphysema
Trauma
Colour Skin colour –
check the
skin, nail beds, lips, tongue, ears and nose
Cyanosis – central or peripheral Central – hypoxaemia
Peripheral – perfusion
abnormality
Chest Shape Barrel chest Emphysema
Pigeon chest Rickets
Movement Symmetrical Asymmetrical Pneumothorax – air
trapped in the pleura
Extreme atelectasis

Chronic Obstructive Pulmonary Disease (COPD)

Key facts

  • Chronic obstructive pulmonary disease (COPD) is a progressive life-­threatening lung disease that causes breathlessness (initially with exertion) and predisposes to exacerbations and serious illness.
  • The Global Burden of Disease Study reports a prevalence of 251 million cases of COPD globally in 2016.
  • Globally, it is estimated that 3.17 million deaths were caused by the disease in 2015 (that is, 5% of all deaths globally in that year).
  • More than 90% of COPD deaths occur in low­ and middle-­income countries.
  • The primary cause of COPD is exposure to tobacco smoke (either active smoking or second­hand smoke).
  • Other risk factors include exposure to indoor and outdoor air pollution and occupational dusts and fumes.
  • Exposure to indoor air pollution can affect the unborn child and represent a risk factor for developing COPD later in life.
  • Some cases of COPD are due to long-term asthma.
  • COPD is likely to increase in coming years due to higher smoking prevalence and aging populations in many countries.
  • Many cases of COPD are preventable by avoidance or early cessation of smoking. Hence, it is important that countries adopt the WHO Framework Convention on Tobacco Control (WHO-FCTC) and implement the MPOWER package of measures so that non-smoking becomes the norm globally.
  • COPD is not curable, but treatment can relieve symptoms, improve quality of life and reduce the risk of death.

Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. This newest definition of COPD, provided by the Global Initiative for Chronic Obstructive Lung Disease, provides a broad description that better explains this disorder and its signs and symptoms (National Institutes of Health [NIH], 2001).

Chronic obstructive pulmonary disease (COPD)

While previous definitions have included emphysema and chronic bronchitis under the umbrella classification of COPD, this was often confusing because most patients with COPD present with overlapping signs and symptoms of these two distinct disease processes.

 COPD may include diseases that cause airflow obstruction (eg, emphysema, chronic bronchitis) or a combination of these disorders. Other diseases such as cystic fibrosis, bronchiectasis, and asthma were previously classified as types of chronic obstructive lung disease. However, asthma is now considered a separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation. COPD can coexist with asthma. Both of these diseases have the same major symptoms; however, symptoms are generally more variable in asthma than in COPD.

People with COPD commonly become symptomatic during the middle adult years, and the incidence of COPD increases with age. Although certain aspects of lung function normally decrease with age (eg, vital capacity and forced expiratory volume in 1 second [FEV1]), COPD accentuates and accelerates these physiologic changes.

Pathophysiology

In COPD, the airflow limitation is both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The inflammatory response occurs throughout the airways, parenchyma, and pulmonary vasculature (NIH, 2001). Because of the chronic inflammation and the body’s attempts to repair it, narrowing occurs in the small peripheral airways. Over time, this injury-and-repair process causes scar tissue formation and narrowing of the airway lumen. Airflow obstruction may also be due to parenchymal destruction as seen with emphysema, a disease of the alveoli or gas exchange units.

In addition to inflammation, processes relating to imbalances of proteinases and antiproteinases in the lung may be responsible for airflow limitation. When activated by chronic inflammation, proteinases and other substances may be released, damaging the parenchyma of the lung. The parenchymal changes may also be consequences of inflammation, environmental, or genetic factors (eg, alpha1 antitrypsin deficiency).

Early in the course of COPD, the inflammatory response causes pulmonary vasculature changes that are characterized by thickening of the vessel wall. These changes may occur as a result of exposure to cigarette smoke or use of tobacco products or as a result of the release of inflammatory mediators (NIH, 2001).

Chronic Bronchitis

Chronic bronchitis, a disease of the airways, is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years. In many cases, smoke or other environmental pollutants irritate the airways, resulting in hypersecretion of mucus and inflammation. This constant irritation causes the mucus-secreting glands and goblet cells to increase in number, ciliary function is reduced, and more mucus is produced. The bronchial walls become thickened, the bronchial lumen is narrowed, and mucus may plug the airway. Alveoli adjacent to the bronchioles may become damaged and fibrosed, resulting in altered function of the alveolar macrophages. This is significant because the macrophages play an important role in destroying foreign particles, including bacteria. As a result, the patient becomes more susceptible to respiratory infection. A wide range of viral, bacterial, and mycoplasmal infections can produce acute episodes of bronchitis. Exacerbations of chronic bronchitis are most likely to occur during the winter.

Emphysema

In emphysema, impaired gas exchange (oxygen, carbon dioxide) results from destruction of the walls of overdistended alveoli. “Emphysema” is a pathological term that describes an abnormal distention of the air spaces beyond the terminal bronchioles, with destruction of the walls of the alveoli. It is the end stage of a process that has progressed slowly for many years. As the walls of the alveoli are destroyed (a process accelerated by recurrent infections), the alveolar surface area in direct contact with the pulmonary capillaries continually decreases, causing an increase in dead space (lung area where no gas exchange can occur) and impaired oxygen diffusion, which leads to hypoxemia. In the later stages of the disease, carbon dioxide elimination is impaired, resulting in increased carbon dioxide tension in arterial blood (hypercapnia) and causing respiratory acidosis. As the alveolar walls continue to break down, the pulmonary capillary bed is reduced.

Consequently, pulmonary blood flow is increased, forcing the right ventricle to maintain a higher blood pressure in the pulmonary artery. Hypoxemia may further increase pulmonary artery pressure. Thus, right-sided heart failure (cor pulmonale) is one of the complications of emphysema. Congestion, dependent edema, distended neck veins, or pain in the region of the liver suggests the development of cardiac failure.

Risk Factors for COPD

  • Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases (Rennard, 1998)
  • Passive smoking
  • Occupational exposure
  • Ambient air pollution
  • Genetic abnormalities, including a deficiency of alpha1-antitrypsin, an enzyme inhibitor that normally counteracts the destruction of lung tissue by certain other enzymes

Clinical Manifestations

COPD is characterized by three primary symptoms:

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  • cough,
  • sputum production, and
  • dyspnea on exertion. These symptoms often worsen over time.
  • Chronic cough and sputum production often precede the development of airflow limitation by many years. However, not all individuals with cough and sputum production will develop COPD.
  • Dyspnea may be severe and often interferes with the patient’s activities.
  • Weight loss is common because dyspnea interferes with eating, and the work of breathing is energy-depleting.

Often the patient cannot participate in even mild exercise because of dyspnea; as COPD progresses, dyspnea occurs even at rest. As the work of breathing increases over time, the accessory muscles are recruited in an effort to breathe. The patient with COPD is at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk for acute and chronic respiratory failure.

  • In COPD patients with a primary emphysematous component, chronic hyperinflation leads to the “barrel chest” thorax configuration. This results from fixation of the ribs in the inspiratory position (due to hyperinflation) and from loss of lung elasticity. Retraction of the supraclavicular fossae occurs on inspiration, causing the shoulders to heave upward. In advanced emphysema, the abdominal muscles also contract on inspiration.

Complications

There are two major life-threatening complications of COPD: respiratory insufficiency and failure.

  • Respiratory failure. The acuity and the onset of respiratory failure depend on baseline pulmonary function, pulse oximetry or arterial blood gas values, comorbid conditions, and the severity of other complications of COPD.
  • Respiratory insufficiency. This can be acute or chronic, and may necessitate ventilator support until other acute complications can be treated.

Assessment and Diagnostic Findings

Diagnosis and assessment of COPD must be done carefully since the three main symptoms are common among chronic pulmonary disorders.

  • Health history. The nurse should obtain a thorough health history from patients with known or potential COPD.
  • Pulmonary function studies. Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and monitor disease progression.
  • Spirometry. Spirometry is used to evaluate airway obstruction, which is determined by the ratio of FEV1 to forced vital capacity.
  • ABG. Arterial blood gas measurement is used to assess baseline oxygenation and gas exchange and is especially important in advanced COPD.
  • Chest x-ray. A chest x-ray may be obtained to exclude alternative diagnoses.
  • CT scan. Computed tomography chest scan may help in the differential diagnosis.
  • Screening for alpha1-antitrypsin deficiency. Screening can be performed for patients younger than 45 years old and for those with a strong family history of COPD.
  • Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, increased retrosternal air space, decreased vascular markings/bullae (emphysema), increased bronchovascular markings (bronchitis), normal findings during periods of remission (asthma).
  • Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or restrictive, to estimate degree of dysfunction and to evaluate effects of therapy, e.g., bronchodilators. Exercise pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary impairment/progression of disease.
  • The forced expiratory volume over 1 second (FEV1): Reduced FEV1 not only is the standard way of assessing the clinical course and degree of reversibility in response to therapy, but also is an important predictor of prognosis.
  • Total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV): May be increased, indicating air-trapping. In obstructive lung disease, the RV will make up the greater portion of the TLC.
  • Arterial blood gases (ABGs): Determines degree and severity of disease process, e.g., most often Pao2is decreased, and Paco2 is normal or increased in chronic bronchitis and emphysema, but is often decreased in asthma; pH normal or acidotic, mild respiratory alkalosis secondary to hyperventilation (moderate emphysema or asthma).
  • DL CO test: Assesses diffusion in lungs. Carbon monoxide is used to measure gas diffusion across the alveocapillary membrane. Because carbon monoxide combines with hemoglobin 200 times more easily than oxygen, it easily affects the alveoli and small airways where gas exchange occurs. Emphysema is the only obstructive disease that causes diffusion dysfunction.
  • Bronchogram: Can show cylindrical dilation of bronchi on inspiration; bronchial collapse on forced expiration (emphysema); enlarged mucous ducts (bronchitis).
  • Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary diseases. COPD is characterized by a mismatch of perfusion and ventilation (i.e., areas of abnormal ventilation in area of perfusion defect).
  • Complete blood count (CBC) and differential: Increased hemoglobin (advanced emphysema), increased eosinophils (asthma).
  • Blood chemistry: alpha1-antitrypsin is measured to verify deficiency and diagnosis of primary emphysema.
  • Sputum culture: Determines presence of infection, identifies pathogen.
  • Cytologic examination: Rules out underlying malignancy or allergic disorder.
  • Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe asthma); atrial dysrhythmias (bronchitis), tall, peaked P waves in leads II, III, AVF (bronchitis, emphysema); vertical QRS axis (emphysema).
  • Exercise ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise program.

Medical Management

Healthcare providers perform medical management by considering the assessment data first and matching the appropriate intervention to the existing manifestation.

Pharmacologic Therapy

  • Bronchodilators. Bronchodilators relieve bronchospasm by altering the smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation.
  • Corticosteroids. A short trial course of oral corticosteroids may be prescribed for patients to determine whether pulmonary function improves and symptoms decrease.
  • Other medications. Other pharmacologic treatments that may be used in COPD include alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators, and narcotics.

Management of Exacerbations

  • Optimization of bronchodilator medications is first-line therapy and involves identifying the best medications or combinations of medications taken on a regular schedule for a specific patient.
  • Hospitalization. Indications for hospitalization for acute exacerbation of COPD include severe dyspnea that does not respond to initial therapy, confusion or lethargy, respiratory muscle fatigue, paradoxical chest wall movement, and peripheral edema.
  • Oxygen therapy. Upon arrival of the patient in the emergency room, supplemental oxygen therapy is administered and rapid assessment is performed to determine if the exacerbation is life-threatening.
  • Antibiotics. Antibiotics have been shown to be of some benefit to patients with increased dyspnea, increased sputum production, and increased sputum purulence.

Surgical Management

Patients with COPD also have options for surgery to improve their condition.

  • Bullectomy. Bullectomy is a surgical option for select patients with bullous emphysema and can help reduce dyspnea and improve lung function.
  • Lung Volume Reduction Surgery. Lung volume reduction surgery is a palliative surgery in patients with homogenous disease or disease that is focused in one area and not widespread throughout the lungs.
  • Lung Transplantation. Lung transplantation is a viable option for definitive surgical treatment of end-stage emphysema.

Nursing Management

Management of patients with COPD should be incorporated with teaching and improving the respiratory status of the patient.

Nursing Assessment

Assessment of the respiratory system should be done rapidly yet accurately.

  • Assess patient’s exposure to risk factors.
  • Assess the patient’s past and present medical history.
  • Assess the signs and symptoms of COPD and their severity.
  • Assess the patient’s knowledge of the disease.
  • Assess the patient’s vital signs.
  • Assess breath sounds and pattern.

Diagnosis

Diagnosis of COPD would mainly depend on the assessment data gathered by the healthcare team members.

  • Impaired gas exchange due to chronic inhalation of toxins.
  • Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, and other complications.
  • Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway irritants.
  • Self-care deficit related to fatigue.
  • Activity intolerance related to hypoxemia and ineffective breathing patterns.

Planning & Goals

Goals to achieve in patients with COPD include:

  • Improvement in gas exchange.
  • Achievement of airway clearance.
  • Improvement in breathing pattern.
  • Independence in self-care activities.
  • Improvement in activity intolerance.
  • Ventilation/oxygenation adequate to meet self-care needs.
  • Nutritional intake meeting caloric needs.
  • Infection treated/prevented.
  • Disease process/prognosis and therapeutic regimen understood.
  • Plan in place to meet needs after discharge.

Nursing Priorities

  1. Maintain airway patency.
  2. Assist with measures to facilitate gas exchange.
  3. Enhance nutritional intake.
  4. Prevent complications, slow progression of condition.
  5. Provide information about disease process/prognosis and treatment regimen.

Nursing Interventions

Patient and family teaching is an important nursing intervention to enhance self-management in patients with any chronic pulmonary disorder.

To achieve airway clearance:

  • The nurse must appropriately administer bronchodilators and corticosteroids and become alert for potential side effects.
  • Direct or controlled coughing. The nurse instructs the patient in direct or controlled coughing, which is more effective and reduces fatigue associated with undirected forceful coughing.

To improve breathing pattern:

  • Inspiratory muscle training. This may help improve the breathing pattern.
  • Diaphragmatic breathing. Diaphragmatic breathing reduces respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration.
  • Pursed lip breathing. Pursed lip breathing helps slow expiration, prevents collapse of small airways, and control the rate and depth of respiration.

To improve activity intolerance:

  • Manage daily activities. Daily activities must be paced throughout the day and support devices can be also used to decrease energy expenditure.
  • Exercise training. Exercise training can help strengthen muscles of the upper and lower extremities and improve exercise tolerance and endurance.
  • Walking aids. Use of walking aids may be recommended to improve activity levels and ambulation.

To monitor and manage potential complications:

  • Monitor cognitive changes. The nurse should monitor for cognitive changes such as personality and behavior changes and memory impairment.
  • Monitor pulse oximetry values. Pulse oximetry values are used to assess the patient’s need for oxygen and administer supplemental oxygen as prescribed.
  • Prevent infection. The nurse should encourage the patient to be immunized against influenza and S. pneumonia because the patient is prone to respiratory infection.

Evaluation

During evaluation, the effectiveness of the care plan would be measured if goals were achieved in the end and the patient:

  • Identifies the hazards of cigarette smoking.
  • Identifies resources for smoking cessation.
  • Enrolls in smoking cessation program.
  • Minimizes or eliminates exposures.
  • Verbalizes the need for fluids.
  • Is free of infection.
  • Practices breathing techniques.
  • Performs activities with less shortness of breath.

Discharge and Home Care Guidelines

It is important for the nurse to assess the knowledge of patient and family members about self-care and the therapeutic regimen.

  • Setting goals. If the COPD is mild, the objectives of the treatment are to increase exercise tolerance and prevent further loss of pulmonary function, while if COPD is severe, these objectives are to preserve current pulmonary function and relieve symptoms as much as possible.
  • Temperature control. The nurse should instruct the patient to avoid extremes of heat and cold because heat increases the temperature and thereby raising oxygen requirements and high altitudes increase hypoxemia.
  • Activity moderation. The patient should adapt a lifestyle of moderate activity and should avoid emotional disturbances and stressful situations that might trigger a coughing episode.
  • Breathing retraining. The home care nurse must provide the education and breathing retraining necessary to optimize the patient’s functional status.

Documentation Guidelines

Documentation is an essential part of the patient’s chart because the interventions and medications given and done are reflected on this part.

  • Document assessment findings including respiratory rate, character of breath sounds; frequency, amount and appearance of secretions laboratory findings and mentation level.
  • Document conditions that interfere with oxygen supply.
  • Document plan of care and specific interventions.
  • Document liters of supplemental oxygen.
  • Document client’s responses to treatment, teaching, and actions performed.
  • Document teaching plan.
  • Document modifications to plan of care.
  • Document attainment or progress towards goals.

 

Cystic Fibrosis

Cystic fibrosis (CF) is the most common fatal autosomal recessive disease among the Caucasian population. An individual must inherit a defective copy of the CF gene (one from each parent) to have CF. Cystic fibrosis is usually diagnosed in infancy or early childhood, but patients may be diagnosed later in life. For individuals diagnosed later in life, respiratory symptoms are frequently the major manifestation of the disease.

Pathophysiology
This disease is caused by mutations in the CF transmembrane conductance regulator protein, which is a chloride channel found in all exocrine tissues. Chloride transport problems lead to thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract as well as increased salt content in sweat gland secretions. In 1989, major breakthroughs were made in this disease with the identification of the CF gene. The ability to detect the common mutations of this gene allows for routine screening for this disease as well as the detection of carriers. Genetic counseling is an important part of health care for couples at risk.
Airflow obstruction is a key feature in the presentation of CF. This obstruction is due to bronchial plugging by purulent secretions, bronchial wall thickening due to inflammation, and, over time, airway destruction. These chronic retained secretions in the airways set up an excellent reservoir for continued bronchial infections.

 

 

 

 

 

 

 

Clinical Manifestations

The pulmonary manifestations of this disease include;

  • a productive cough, wheezing, hyperinflation of the lung fields on chest x-ray, and pulmonary function test results consistent with obstructive airways disease.
  • Colonization of the airways with pathogenic bacteria usually occurs early in life.
  • Staphylococcus aureus and Haemophilus influenzae are common organisms during early childhood. As the disease progresses, Pseudomonas aeruginosa is ultimately isolated from the sputum of most patients.
  • Upper respiratory manifestations of the disease include sinusitis and nasal polyps.

Nonpulmonary clinical manifestations include;

  • gastrointestinal problems (eg, pancreatic insufficiency, recurrent abdominal pain, biliary cirrhosis, vitamin deficiencies, recurrent pancreatitis, weight loss),
  • genitourinary problems (male and female infertility), and
  • Clubbing of the extremities.

Assessment and Diagnostic Findings

Most of the time, the diagnosis of CF is made based on an elevated result of a sweat chloride concentration test, along with clinical signs and symptoms consistent with the disease. Repeated sweat chloride values of greater than 60 mEq/L distinguish most individuals with CF from those with other obstructive diseases. A molecular diagnosis may also be used in evaluating common genetic mutations of the CF gene.

Medical Management
Pulmonary problems remain the leading cause of morbidity and mortality in CF. Because chronic bacterial infection of the airways occurs in individuals with CF, control of infections is key in the treatment.

  • Antibiotic medications are routinely prescribed for acute pulmonary exacerbations of the disease. Depending upon the severity of the exacerbation, aerosolized, oral, or intravenous antibiotic therapy may be used. Antibiotic agents are selected based upon the results of a sputum culture and sensitivity. Patients with CF have problems with bacteria that are resistant to multiple drugs and require multiple courses of antibiotic agents over long periods of time.
  • Bronchodilators are frequently administered to decrease airway obstruction. Differing pulmonary techniques are used to enhance secretion clearance. Examples include manual postural drainage and chest physical therapy, high-frequency chest wall oscillation, and other devices that assist in airway clearance (PEP masks [masks that generate positive expiratory pressure], “flutter devices” [devices that provide an oscillatory expiratory pressure pattern with positive expiratory pressure and assist with expectoration of secretions]).
  • Inhaled mucolytic agents such as dornase alfa (Pulmozyme) or N-acetylcysteine (Mucomyst) may also be used. These agents help to decrease the viscosity of the sputum and promote expectoration of secretions.
  • Anti-inflammatory: To decrease the inflammation and ongoing destruction of the airways, anti-inflammatory agents may also be used. These may include inhaled corticosteroids or systemic therapy. Other anti-inflammatory medications have also been studied in CF. Ibuprofen was studied in children with CF and some benefit was demonstrated, but there is little information on its use in young or older adults with CF.
  • Supplemental oxygen is used to treat the progressive hypoxemia that occurs with CF. It helps to correct the hypoxemia and may minimize the complications seen with chronic hypoxemia (pulmonary hypertension).
  • Lung transplantation is an option for a small, select population of CF patients. A double lung transplant technique is used due to the chronically infected state of the lungs seen in end-stage CF. Because there is a long waiting list for lung transplant recipients, many patients die while awaiting a transplant.
  • Gene therapy is a promising approach to management, with many clinical trials underway. It is hoped that various methods of administering gene therapy will carry healthy genes to the damaged cells and correct defective CF cells. Efforts are underway to develop innovative methods of delivering therapy to the CF cells of the airways.

Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:

  • Ineffective airway clearance related to thick, tenacious mucus production.
  • Ineffective breathing pattern related to tracheobronchial obstruction.
  • Risk for infection related to bacterial growth medium provided by pulmonary mucus and impaired body defenses.
  • Imbalanced nutrition: less than body requirements related to impaired absorption of nutrients.
  • Anxiety related to hospitalization.
  • Compromised family coping related to child’s chronic illness and its demands on caregivers.
  • Deficient knowledge of the caregiver related to illness, treatment, and home care.

Nursing Management
Nursing care of the adult with CF includes assisting the patient to manage pulmonary symptoms and to prevent complications of CF.

  • Specific nursing measures include strategies that promote removal of pulmonary secretions; chest physiotherapy, including postural drainage, chest percussion, and vibration, and breathing exercises are implemented and are taught to the patient and to the family when the patient is very young.
  • The patient is taught the early signs and symptoms of respiratory infection and disease progression that indicate the need to notify the primary health care provider.
  • The nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. Because CF is a life-long disorder, patients often have learned to modify their daily activities to accommodate their symptoms and treatment modalities.
  • Although gene therapy and double lung transplantation are promising therapies for CF, they are limited in availability and largely experimental. As a result, the life expectancy of adults with CF is shortened.
  • For the patient whose disease is progressing and who is developing increasing hypoxemia, preferences for end-of-life care should be discussed, documented, and honored.
  • Patients and family members need support as they face a shortened life span and an uncertain future.

 

Asthma

Asthma is a chronic inflammatory disorder of the airways associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing. These episodes are usually associated with airflow obstruction within the lung, often reversible, either spontaneously or with treatment.

Factors that precipitate/aggravate asthma include: allergens, infection, exercise, drugs (aspirin), tobacco, etc.

Pathophysiology:-

Airway inflammation is the primary problem in asthma. An initial event in asthma appears to be the release of inflammatory mediators triggered. The mediators are released from bronchial mast cells, alveolar macrophages, and epithelial cells. Some mediators directly cause acute bronchoconstriction.” The inflammatory mediators also direct the activation of eosinophils and neutrophils, and their migration to the airways, where they cause injury Called “late-phase asthmatic response” results in epithelial damage, airway edema, mucus hypersecretion and hyper responsiveness of bronchial smooth muscle varying airflow obstruction leads to recurrent episodes of wheezing, breathlessness, chest tightness and cough.

Asthma Pathophysiology airway diagram

info-graphic about Severe Asthma Pathophysiology, Healthy airway and what is severe asthma

Causes/Triggers of Asthma:

The exact causes of asthma are still unknown but we do know that children are more likely to have asthma if other members of the family also have it. Related conditions like hay fever, eczema or food allergies can also increase the risk of asthma.

Asthma Triggers Smoking during pregnancy or exposing a child to tobacco smoke will increase their risk of developing asthma. Being overweight also increases the risk of developing asthma.

Though some children lose their symptoms as they grow older, asthma is a chronic disease so symptoms may come back later in life.

  • Asthma is a breathing disease which is triggered by various allergies and substance, like:
    • polluted matters, smoking, animal products and many more.
  • Asthma problems can be caused by different foods which can react on the immune system of the body. Some people have allergy with particular food and various symptoms are appeared in your body like swelling, vomiting, diarrhea, rash, wheezing and breathing problems. The use of foods like peanuts, shellfish, eggs, various dairy products can be harmful for the patients so they should avoid all these foods. All such foods and wine containing histamine can cause development in asthma.
  • The fizzy drinks, prepared salads and meats, home brewed beer and wine can contain the allergic reaction. If you have some problems of allergy, then you should contact with specialist for the allergic problems. The women can face the asthma problems during their periods, pregnancy, puberty and menopause.

The following things can trigger an asthma attack:

  • Colds and Viral Infections
  • House Dust Mites
  • Fur and dander from pets
  • Changes in weather, and cold air
  • Pollen
  • Tobacco smoke and pollution
  • Mould
  • Chemicals
  • Allergies
  • Exercise

Clinical Manifestations

The three most common symptoms of asthma are cough, dyspnea, and wheezing. In some instances, cough may be the only symptom. Asthma attacks often occur at night or early in the morning, possibly due to circadian variations that influence airway receptor thresholds.

  • Cough. There are instances that cough is the only symptom.
  • Dyspnea. General tightness may occur which leads to dyspnea.
  • Wheezing. There may be wheezing, first on expiration, and then possibly during inspiration as well.
  • Asthma attacks frequently occur at night or in the early morning.
  • An asthma exacerbation is frequently preceded by increasing symptoms over days, but it may begin abruptly.
  • Expiration requires effort and becomes prolonged.
  • As exacerbation progresses, central cyanosis secondary to severe hypoxia may occur.
  • Additional symptoms, such as diaphoresis, tachycardia, and a widened pulse pressure, may occur.
  • Exercise-induced asthma: maximal symptoms during exercise, absence of nocturnal symptoms, and sometimes only a description of a “choking” sensation during exercise.
  • A severe, continuous reaction, status asthmaticus, may occur. It is life-threatening.
  • Eczema, rashes, and temporary edema are allergic reactions that may be noted with asthma.

Assessment of the severity of asthma attack

  • The severity of the asthma attack must be rapidly evaluated by the following clinical criteria. Not all signs are necessarily present.

Assessment of severity in children over 2 years and adults

Mild to moderate attack Severe attack Life threatening attack
to talk in sentences

Respiratory rate (RR)
Children 2-5 years ≤ 40/ minute

Children > 5 years ≤ 30/ minute

Heart rate

Children 2-5 years ≤ 140/ minute
Children > 5 years ≤ 125/ minute
and
No criteria of severity

Cannot complete sentences in one breath
or
Too breathless to talk or feed

RR

Children 2-5 years > 40/minute
Children > 5 years > 30/minute
Adults ≥ 25/minute

Heart rate
Children 2-5 years > 140/minute
Children > 5 years > 125/minute
Adults ≥ 110/minute

SpO2 ≥ 92%

Altered level of consciousness
(drowsiness, confusion, coma)

Exhaustion
Silent chest
Paradoxical thoracoabdominal movement
Cyanosis
Collapse
Bradycardia in children or arrhythmia/ hypotension in adults

 

 

SpO2 < 92%

Assessment and Diagnostic Findings

A complete family, environmental, and occupational history is essential.

  • Positive family history. Asthma is a hereditary disease, and can be possibly acquired by any member of the family who has asthma within their clan.

  • Environmental factors. Seasonal changes, high pollen counts, mold, pet dander, climate changes, and air pollution are primarily associated with asthma.
  • Comorbid conditions. Comorbid conditions that may accompany asthma may include gastroeasophageal reflux, drug-induced asthma, and allergic broncopulmonary aspergillosis.

Complications

Complications of asthma may include status asthmaticus, respiratoryfailure, pneumonia, and atelectasis. Airway obstruction, particularly during acute asthmatic episodes, often results in hypoxemia, requiring the administration of oxygen and the monitoring of pulse oximetry and arterial blood gases. Fluids are administered because people with asthma are frequently dehydrated from diaphoresis and insensible fluid loss with hyperventilation.

Medical Management

Immediate intervention is necessary because the continuing and progressive dyspnea leads to increased anxiety, aggravating the situation.

Goals of Asthma Therapy

  • Prevent recurrent exacerbations and minimize the need for emergency department visits or hospitalizations
  • Maintain (near‐) “normal” pulmonary function
  • Maintain normal activity levels (including exercise and other physical activity)
  • Provide optimal pharmacotherapy with minimal or no adverse effects

Pharmacologic Therapy

There are two classes of medications—long-acting control and quick-relief medications—as well as combination products.

  • Short-acting beta2-adrenergic agonists
  • Anticholinergics
  • •Corticosteroids: metered-dose inhaler (MDI)
  • Leukotriene modifiers inhibitors/antileukotrienes
  • Methylxanthines

Mild to moderate attack

– Reassure the patient; place him in a 1/2 sitting position.
– Administer:

• salbutamol (aerosol): 2 to 4 puffs every 20 to 30 minutes, up to 10 puffs if necessary during the first hour. In children, use a spacer 1to ease administration (use face mask in children under 3 years).
Single puffs should be given one at a time, let the child breathe 4 to 5 times from the spacer before repeating the procedure.

• prednisolone PO: one dose of 1 to 2 mg/kg
– If the attack is completely resolved: observe the patient for 1 hour (4 hours if he lives far from the health centre) then give outpatient treatment: salbutamol for 24 to 48 hours (2 to 4 puffs every 4 to 6 hours depending on clinical evolution) and prednisolone PO (1 to 2 mg/kg once daily) to complete 3 days of treatment.
– If the attack is only partially resolved, continue with salbutamol 2 to 4 puffs every 3 to 4 hours if the attack is mild; 6 puffs every 1 to 2 hours if the attack is moderate, until symptoms subside, then when the attack is completely resolved, proceed as above.
– If symptoms worsen or do not improve, treat as sever attack.

Severe attack
– Hospitalise the patient; place him in a 1/2 sitting position.
– Administer:
• oxygen continuously, at least 5 litres/minute or maintain the SpO2 between 94 and 98%.
• salbutamol (aerosol): 2 to 4 puffs every 20 to 30 minutes, up to 10 puffs if necessary in children under 5 years, up to 20 puffs in children over 5 years and adults. Use a spacer to increase effectiveness, irrespective of age.

or salbutamol (solution for nebulisation), see Life-threatening attack
• prednisolone PO: one dose of 1 to 2 mg/kg
In the case of vomiting, until the patient can tolerate oral prednisolone, use hydrocortisone IV:
Children 1 month to < 5 years: 4 mg/kg every 6 hours (max. 100 mg per dose)
Children 5 years and over and adults: 100 mg every 6 hours
– If the attack is completely resolved, observe the patient for at least 4 hours. Continue the treatment with salbutamol for 24 to 48 hours (2 to 4 puffs every 4 hours) and prednisolone PO (1 to 2 mg/kg once daily) to complete 3 days of treatment.

Reassess after 10 days: consider long-term treatment if the asthma attacks have been occurring for several months. If the patient is already receiving long-term treatment, reassess the severity of the asthma (see table) and review compliance and correct use of medication and adjust treatment if necessary.
– If symptoms worsen or do not improve, see Life-threatening attack.

Life-threatening attack (intensive care)
– Insert an IV line.
– Administer:
• oxygen continuously, at least 5 litres/minute or maintain the SpO2 between 94 and 98%.
• salbutamol + ipratropium nebuliser solutions using a nebuliser:

 

Children 1 month to < 5 years salbutamol 2.5 mg + ipratropium 0.25 mg every 20 to 30 minutes
Children 5 to < 12 years salbutamol 2.5 to 5 mg + ipratropium 0.25 mg every 20 to 30  minutes
Children 12 years and over and adults salbutamol 5 mg + ipratropium 0.5 mg every 20 to 30 minutes

The two solutions can be mixed in the nebuliser reservoir.

corticosteriods (prednisolone PO or hydrocortisone IV) as for severe attack
– If the attack is resolved after one hour: switch to salbutamol aerosol and continue prednisolone PO as for severe attack
– If symptoms do not improve after one hour:

administer a single dose of magnesium sulfate by IV infusion in 0.9% sodium chloride over 20 minutes, monitoring blood pressure:

Children over 2 years: 40 mg/kg

Adults: 1 to 2 g

continue salbutamol by nebulisation and corticosteriods, as above.

Notes:

– In pregnant women, treatment is the same as for adults. In mild or moderate asthma attacks, administering oxygen reduces the risk of foetal hypoxia.

– For all patients, irrespective of the severity of the asthma attack, look for underlying lung infection and treat accordingly.

If a conventional spacer is not available, use a 500 ml plastic bottle: insert the mouthpiece of the inhaler into a hole made in the bottom of the bottle (the seal should be as tight as possible). The child breathes from the mouth of the bottle in the same way as he would with a spacer. The use of a plastic cup instead of a spacer is not recommended (ineffective).

Nursing Management

The immediate nursing care of patients with asthma depends on the severity of symptoms. The patient and family are often frightened and anxious because of the patient’s dyspnea.
Therefore, a calm approach is an important aspect of care.

  • Assess the patient’s respiratory status by monitoring the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.
  • Obtain a history of allergic reactions to medications before administering medications.
  • Identify medications the patient is currently taking.
  • Administer medications as prescribed and monitor the patient’s responses to those medications; medications may include an antibiotic if the patient has an underlying respiratory infection.
  • Administer fluids if the patient is dehydrated.
  • Assist with intubation procedure, if required.

Promoting Home- and Community-Based Care

Teaching Patients Self-Care

  • Teach patient and family about asthma (chronic inflammatory), purpose and action of medications, triggers to avoid and how to do so, and proper inhalation technique.
  • Instruct patient and family about peak-flow monitoring.
  • Teach patient how to implement an action plan and how and when to seek assistance.
  • Obtain current educational materials for the patient based on the patient’s diagnosis, causative factors, educational level, and cultural background.

Continuing Care

  • Emphasize adherence to prescribed therapy, preventive measures, and need for follow-up appointments.
  • Refer for home health nurse as indicated.
  • Home visit to assess for allergens may be indicated (with recurrent exacerbations).
  • Refer patient to community support groups.
  • Remind patients and families about the importance of health promotion strategies and recommended health screening.

Appendicitis

Introduction:

Appendicitis is an inflammation of the appendix.
It is a medical emergency that usually leads to removal of the appendix before it can rupture, as this can cause infection and even death.
Surgically removing the appendix appears to have no effect on the digestive system.
Appendicitis can occur at any age but usually affects children and young adults.
Appendicitis is found on the right lower side of the abdomen and connects to the cecum of the large intestine. It looks like a protruding worm or finger-like structure coming out of the large intestine, specifically the ascending colon.
The role of the appendix: it plays a role in storing the “good” bacteria in your GI tract while the tract is recovering from a diarrhea illness (so it helps maintain healthy GI flora.

Types of Appendicitis
The two types of appendicitis depending on the onset, which are:

  • Acute Appendicitis – It develops very fast within a few days to hours, and requires prompt medical treatment or surgery.
  • Chronic Appendicitis – Here, the inflammation lasts for a long time. It is a rare condition.

And depending on the complications:

  • Simple Appendicitis – Cases with no complications.
  • Complex Appendicitis – Cases that involve complications like appendix rupture or abscess.

Causes
The exact causes are not clear, but it usually involves:

  • a blockage of the lumen of the appendix (leading to increased pressure and impaired bloodflow, which results in inflammation).
  • This is usually caused by faeces, but bacterial or viral infections in the digestive tract can lead to swelling of lymph nodes (lymphoid hyperplasia), which puts pressure on the appendix and causes obstruction.
  • Untreated, the appendix can become gangrenous or rupture. If it ruptures, the infection may be released into the abdomen.
  • inflammatory bowel disease.
  • stool, parasites, or growths that can clog your appendiceal lumen.
  • trauma to your abdomen.

Pathophysiology
Appendicitis occurs when the appendix becomes acutely inflamed. It’s not entirely known why appendicitis occurs however it is thought to be due to the lumen of the appendix becoming blocked by a faecolith, normal faecal matter or lymphoid hyperplasia due to a viral infection.

https://teachmepaediatrics.com/wp-content/uploads/2018/10/Appendicitis-e1540220601487-1024x733.jpeg Once obstructed, there is reduced blood flow to the tissue and bacteria is able to multiply. Due to the lumen being obstructed, the pressure within the appendix increases and this reduces venous drainage, resulting in ischaemia. If untreated the ischaemia can lead to necrosis and gangrene. At this stage, the appendix is at risk of perforating. It takes around 72hrs for perforation to occur from when the appendix becomes obstructed. Once the appendix perforates, bacteria and inflammatory cells are released into the surrounding structures. This then causes inflammation of the peritoneum and the child develops peritonitis causing diffuse abdominal pain.

Signs and Symptoms of Appendicitis

Remember “Appendix”

  • Abdominal pain (will be dull at first with pain at or around the belly button that radiates to the right lower quadrant and it will localize at this spot)
  • Point of McBurney’s will have the most pain (found one-third distance between the belly button and anterior superior iliac spine)
  • Poor appetite
  • Elevated temperature
  • Nausea/vomiting
  • Desire to be in the fetal position to relieve pain (side lying with knees bent)
  • Increased WBC, inability to pass gas or have a bowel movement (constipation..can have diarrhea too)
  • eXperiences rebound tenderness (when pressure is applied to the right lower quadrant it hurts but it HURTS MORE when the pressure is released) and abdominal rigidity on palpation (involuntary stiffening of the abdominal muscle when abdomen palpated).

Complications

If appendicitis is left untreated, a complication could occur.

Perforation of the appendix. This is a major complication of appendicitis, which can lead to peritonitis, abscess formation, or portal pylephlebitis.
Perforation generally occurs 24 hours after the onset of pain.
Symptoms include a fever of 37.7⁰C or greater, a toxic appearance, and continued abdominal pain or tenderness.

Assessment and Diagnostic Findings
Diagnosis is based on the results of a complete physical examination and on laboratory findings and imaging studies.

  • CBC count: A complete blood cell count shows an elevated WBC count, with an elevation of the neutrophils.
  • Imaging studies: Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel.
  • Pregnancy test: A pregnancy test may be performed for women of childbearing age to rule out ectopic pregnancy and before x-rays are obtained.
  • Laparoscopy: A diagnostic laparoscopy may be used to rule out acute appendicitis in equivocal cases.
  • C-reactive protein: Protein produced by the liver when bacterial infections occur and rapidly increases within the first 12 hours.

Medical Management
Medical management should be performed carefully to avoid altering the presenting symptoms.

  • IV fluids: To correct fluid and electrolyte imbalance and dehydration, IV fluids are administered prior to surgery.
  • Antibiotic therapy: To prevent sepsis, antibiotics are administered until surgery is performed.
  • Drainage: When perforation of the appendix occurs, an abscess may form and patient is initially treated with antibiotics and the surgeon may place a drain in the abscess.

Surgical Management
Immediate surgery is typically indicated if appendicitis is diagnosed.

  • Appendectomy. Appendectomy or the surgical removal of the appendix is performed as soon as it is possible to decrease the risk of perforation.
  • Laparotomy and laparoscopy. Both of these procedures are safe and effective in the treatment of appendicitis with perforation.

Nursing Management

  • A focus of the nurses’ management is the preparation of the patient for surgery.

Nursing Assessment

Assessment of a patient with appendicitis may be both objective and subjective.

  • Assess the level of pain.
  • Assess relevant laboratory findings.
  • Assess patient’s vital signs in preparation for surgery.

Diagnosis
Based on the assessment data, the most appropriate diagnoses for a patient with appendicitis are:

  • Acute pain related to obstructed appendix.
  • Risk for deficient fluid volume related to preoperative vomiting, postoperative restrictions.
  • Risk for infection related to ruptured appendix.
  • Planning & Goals
  • Main Article: 4 Appendectomy Nursing Care Plans

Goals for a patient with appendicitis include:

  • Relieving pain.
  • Preventing fluid volume deficit.
  • Reducing anxiety.
  • Eliminating infection due to the potential or actual disruption of the GI tract.
  • Maintaining skin integrity.
  • Attaining optimal nutrition.

Nursing Interventions

  • The nurse prepares the patient for surgery.
  • IV infusion. An IV infusion is made to replace fluid loss and promote adequate renal functioning.
  • Antibiotic therapy. Antibiotic therapy is given to prevent infection.
  • Positioning. After the surgery, the nurse places the patient on a High-fowler’s position to reduce the tension on the incision and abdominal organs, thereby reducing pain.
  • Oral fluids. When tolerated, oral fluids could be administered.

Evaluation

  • Relieved pain.
  • Prevented fluid volume deficit.
  • Reduced anxiety.
  • Eliminated infection due to the potential or actual disruption of the GI tract.
  • Maintained skin integrity.
  • Attained optimal nutrition.

Discharge and Home Care Guidelines

Discharge teaching for patient and family is imperative.

  • Removal of sutures. The nurse instructs the patient to make an appointment with the surgeon to remove the sutures between the 5th and 7th days after surgery.
  • Activities. Heavy lifting is to be avoided postoperatively; however, normal activity can be resumed within 2 to 4 weeks.
  • Home care. A home care nurse may be needed to assist with incision care and to monitor the patient for complications and wound healing.

Documentation Guidelines

The focus of documentation in patients with appendicitis should include:

  • Client’s description of response to pain.
  • Acceptable level of pain.
  • Prior medication use.
  • Results of laboratory tests.
  • Surgical site.
  • Signs and symptoms of infectious process.
  • Recent or current antibiotic therapy.
  • Plan of care.

Teaching plan.

  • Response to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcomes.
  • Modifications to plan of care.

Long term needs.

Nursing Intervention

Preoperative interventions

  • Maintain NPO status.
  • Administer fluids intravenously to prevent dehydration.
  • Monitor for changes in level of pain.
  • Monitor for signs of ruptured appendix and peritonitis
  • Position right-side lying or low to semi fowler position to promote comfort.
  • Monitor bowel sounds.
  • Apply ice packs to abdomen every hour for 20-30 minutes as prescribed.
  • Administer antibiotics as prescribed
  • Avoid the application of heat in the abdomen.
  • Avoid laxatives or enema.

Postoperative interventions

  • Monitor temperature for signs of infection.
  • Assess incision for signs of infection such as redness, swelling and pain.
  • Maintain NPO status until bowel function has returned.
  • Advance diet gradually or as tolerated or as prescribed when bowel sound return.
  • If ruptured of appendix occurred, expect a Penros drain to be inserted, or the incision maybe left to heal inside out.
  • Expect that drainage from the Penros drain maybe profuse for the first 2 hours.

Frequently Asked Questions

1. How Do You Rule Out Appendicitis?

  • Appendicitis can be ruled out by using brief case history, physical examinations, computed tomography scan, urine analysis, ultrasound abdomen, anal examinations, an x-ray of the abdomen, and blood examination.

2. How Long Can You Have Appendicitis Before It Bursts?

  • The duration taken for bursting depends on the type of appendicitis. In the case of chronic appendicitis, it lasts for a long period, whereas in the case of acute conditions, symptoms will appear suddenly and immediate surgery is needed.

3. What Does Appendicitis Feel Like?

  • Appendicitis pain might be mild or severe. There will be fever, abdominal pain, navel pain, difficulty in moving around, loss of appetite, and anal pain in some cases. There may also be vomiting, diarrhea, and nausea.

4. How Bad Is Appendicitis Pain?

  • There will be sharp pricking pain in the abdomen and the pain worsens by pressing the painful area, moving around. Sometimes, even coughing, and sneezing worsens the pain. There will be difficulty in sitting in a particular place for a long time. There will also be difficulty in passing urine.

5. How Do You Check for Appendicitis at Home?

  • There are no standard methods for the examination of appendicitis at home, but we can check for any swelling in the abdominal area. If we have basic knowledge and ideas about appendicitis we can palpate the abdomen and rule out in some cases.

6. How Does Someone Get Appendicitis?

  • Any blockages in the lining of the appendix lead to appendicitis. This is mainly due to the food items we consume and seeds of fruits that block the passage. It may lead to infection and rupture in the appendix region and sometimes pus discharges also.

7. Should You Feel for Appendicitis?

  • Appendicitis treated at an early time is easily curable but in cases where it is left untreated leads to fatal conditions. So, it is necessary to start the treatment faster. This will make the condition simple.

8. How Does Appendicitis Pain Start?

  • The pain usually comes and goes for a short period of time in the belly and navel region. It starts with pain around the navel region which makes it difficult in sitting and moving. If you are feeling too much pain, you should consult your doctor immediately.

9. What Is the Recovery Time for Appendicitis?

  • Usually, it takes around one to three days for recovery for laparoscopy. It usually takes two to four weeks after surgery to return to our routine life. Depending on the severity of the surgery, and the patient the recovery time may be extended. You should ask your doctor for instructions that are to be followed.

10. How Quickly Does Appendicitis Come On?

  • Appendicitis comes so quickly that symptoms appear within the first 24 hours. Later on, any disturbance and food items lead to further signs and rupture. Any disturbance to the regions leads to further signs.

11. How Long Are a Patient Stays in the Hospital for Appendicitis?

  • The patient stays in the hospital just for three days. The patient is admitted to the hospital one day before the surgery. This is done so that the patient can adapt to the environment before the surgery. The next day surgery is performed. The patient is asked to stay in the hospital for another day and then they can be discharged if the doctor advises them to do so.

12. How Quickly Does Appendicitis Develop?

  • The degree of pain and the duration it takes to show the symptoms might vary. Appendicitis usually develops in teenagers, the symptoms appear very early in addition some food items lead to rupture of the appendix. Symptoms and signs appear in an early stage. However, you should consult your doctor if you experience pain for more than one day.

13. Where Does Your Stomach Hurt With Appendicitis?

  • Initially, the pain starts near the belly and in the navel region, and later on the pain travels to the abdominal region, mainly to the right abdomen. There will be swelling in the stomach region which can be identified by palpation by the doctors. Palpation is the procedure of investigation done by touching and pressing.

14. What Is Appendicitis Surgery?

  • For severe cases of appendicitis, appendectomy is done. It is the surgical removal of the appendix. This is usually done by open surgery. Nowadays, it is done using a laser. The surgery that is done using a laser is known as laparoscopy. In which three holes are made and the further procedure is carried out.

15. What Foods Make Appendicitis Worse?

  • Undigested food makes the condition of the appendix to worsen. Seeds of fruits and vegetables are also harmful. Medications that are taken to relieve pain leads to the rupture of the appendix. This makes the condition even worsen. Some doctors say that spicy food items also worsen the condition of appendicitis.

16. What are the early signs and symptoms of appendicitis?

The signs and symptoms of appendicitis are:

– Nausea.

– Vomiting.

– Loss of appetite.

– Sudden and severe pain in the right side of the lower abdomen.

– The pain begins in the navel that shifts to the right side of the abdomen.

– Severe pain will be experienced while walking, coughing, and movements.

References:

https://nurseslabs.com/appendicitis/

http://nursingfile.com/nursing-care-plan/nursing-interventions/nursing-interventions-for-appendicitis.html

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/appendectomy

https://www.healthline.com/health/appendicitis#tests

https://www.icliniq.com/articles/gastro-health/appendicitis

https://teachmepaediatrics.com/surgery/abdominal/acute-appendicitis/

First Aid

Wound: Abnormal break in skin which permits the escape of blood, and may allow the entrance of germs, causing infection.

Types of Wound:

  1. Incise Wound – Clean cut caused by sharp instrument.
  2. Laceration Wound – Jagged cut or tear caused by sharp irregular edges.
  3. Contusion – Caused by blunt instrument / fall against hard surface. Skin is not broken.
  4. Abrasion – Simple scrapes and scratches usually from a sliding fall.
  5. Puncture Wound – Penetrating wound by sharp, pointed instrument. Can result in serious internal injury.
  6. Stab Wound – Caused by a bladed object.
  7. Gun Shot Wound

Ways to Stop Bleeding:

  1. Direct pressure
  2. Indirect pressure
  3. Elevation

Wound Management:
Slight Bleeding
-Wash your hands and wear a pair of gloves.
– Rinse wound with running water.
– Dab gently to dry.
– Apply direct pressure or elevation if bleeding still occurs.
– Cover wound with sterile swab.
– Clean surrounding area of skin with water and soap.
– When cleaning, wipe away from wound and use each swab only once.
– Avoid wiping away blood clots.
– Pat dry.
– Dress wound with adhesive dressing.

Severe Bleeding
Aim of managing severe bleeding: a) control bleeding b) minimize risk of infection
– Lay casualty down to prevent shock.
– Support injured part.
– Send to hospital.
– Wash hands.

Bandaging:

  1. Triangular bandage (Reef Knot – L over R; R over L)
  2. Broad bandage
  3. Narrow bandage

Slings and Bandaging:

  1. Simple sling
  2. Elevated sling
  3. Scalp bandage
  4. Palm bandage
  5. Fist bandage

Fracture: A break or crack in the bone caused by direct force and indirect force.

Type:

  1. Closed or simple fracture (no wound)
  2. Open or compound fracture (wound is present)
  3. Comminuted (totally crushed)
  4. Green stick injury (In children; mixture of bend and break)
  5. Unstable fracture

Management of Closed Fractures:

  1. Do not move the casualty until you support the injured part.
  2. Steady and support the injured part.
  3. Immobilize the injured part using bandages and slings.
  4. Elevate the injured part.
  5. Treat for shock if possible.
  6. Check circulation every 10 minutes.
  7. Send to hospital.
  8. Do not give him anything to eat or drink.

Management of Open Fractures:

  1. Cover wound with sterile / clean dressing.
  2. Control bleeding.
  3. If wound is jutting, place padding.
  4. Immobilize the injured part.

Dislocation: Displacement of a bone at a joint caused by strong force, wrenching the bone into an abnormal position or violent muscle contraction.

Sprain: Injury to a ligament at or near a joint frequently caused by wrenching movement at joint that tears the surrounding tissue.

Strains: Partial tearing of the muscles at the junction of muscle and tendon that joins it to a bone.

Management of Sprain and Strains (Soft Tissue Injury):

R Rest
I Ice – Reduce swelling
C Compression
E Elevation

If injury is very bad, send the casualty to the hospital.

Cramps: Sudden, involuntary and painful muscle spasm.

Cramp in Foot:

  1. Ask casualty to stand on toes.
  2. Massage foot with fingers.

Cramp in Calve:

  1. Straighten the knee.
  2. Draw the foot firmly and steadily upwards towards the shin.
  3. Massage.

Cramp in Back of Thigh:

  1. Straighten the knee by raising his leg.
  2. Massage the muscles.

Cramp in Front of Thigh:

  1. Bend knee.
  2. Massage muscles slowly.

Signs & Symptoms:

  1. Difficult to move a limb
  2. Pain near the site of injury
  3. Tenderness
  4. Distortion
  5. Swelling
  6. Bruising
  7. Shortening, bending or twisting of the limb
  8. Crepitus (sound) caused by grating of the bone end

Lifting and Moving Casualty

Rules:

  1. Do not move casualty unless absolutely necessary.
  2. Explain to casualty what you are doing.
  3. Never move casualty alone.
  4. Instruct helpers what they are supposed to do.
  5. Protect yourself using the correct techniques.
  6. Ensure casualty’s safety.

Correct Lifting Techniques:

  1. Place feet comfortably apart, one slightly in front of the other.
  2. Keep back straight.
  3. Bend your knees.
  4. Grip with both hands.
  5. Keep weight of person you are lifting as close to you as possible.

Lifting Method:

Casualty is conscious and able to walk:

  1. Use the human crutch

Casualty is conscious but unable to walk:

  1. Pick-a-back
  2. Drag method
  3. 4 handed seat
  4. 3 handed seat
  5. 2 handed seat
  6. Fore & aft
  7. Carry chair

Casualty is unconscious:

  1. Cradle method
  2. Drag method
  3. Fore & aft
  4. Stretcher method

 

MULTIPLE SCLEROSIS

Multiple sclerosis (MS) is a chronic demyelinating disease that affects the myelin sheath of neurons in the CNS.

Multiple-Sclerosis-Infographic Multiple sclerosis is a disease that causes vision problems, numbness and tingling, muscle weakness, and other problems. It happens when the body’s infection-fighting system attacks and damages nerve cells and their connections in the brain and spinal cord.

When the body’s infection-fighting system, called the “immune system,” attacks the body’s own cells, it is called an “autoimmune response.” It causes damage to myelin, the protective coating around the nerves. When myelin is damaged, messages can no longer be clearly transmitted from the brain and spinal cord to other parts of the body. Many people refer to multiple sclerosis as “MS.”

INCIDENCE

  • Onset occurs between 20-40 years of age.
  • Women are more affected than men. (AANN, 2011).
  • Whites are more affected than Hispanics, blacks, or Asians.
  • Most prevalent in colder climates of North America & Europe.
  • Migration.

ETIOLOGY & RISK FACTORS

  • Exact cause is not known yet.
  • Most theories suggest that MS is an immunogenetic viral disease (with Epstein Barr virus).

Risk factors are:

  • Age (most of the time between 20-40 yrs).
  • Sex (women have more chance).
  • Family history (genetic susceptibility).
  • Certain infections (like Epsteinbarr virus).
  • Climate (more in cold climate areas).
  • Certain auto-immune diseases (higher risks with thyroid disease, type-1 DM or IBD).
  • Smoking.
  • Stress, fatigue.
  • Physical injury.
  • Pregnancy (may relating to stress to labour, or puerperium).

PATHOPHYSIOLOGY

Due to etiological factors

Activated T-cells (which recognise self Ag) expressed in CNS, &

Macrophages (B-cells) enters the brain from peripherral circulation

Production of inflammatory cytokines & reactive O2 species

Inflammation

Then activated T-cells & B-cells cause

demyelination and destruction of oligodendrocytes

Formation of plaque

Causes scarring & destruction of sheath

Compensatory system starts causing subsidation of edema & inflammation

After that some remyelination process occurs which is often incomplete

Multiple sclerosis.

CLINICAL MANIFESTATIONS

The course of illness varies from person to person.

  1. Fatigue is the lack of physical and mental energy that impacts daily tasks. Fatigue can be physical or mental and is not correlated to how much rest or sleep a person gets. It is one of the most common symptoms and impacts about 80 percent of people living with MS. It can be http://nursingfile.com/wp-content/uploads/2013/12/multiple-sclerosis-249x300.jpg the most debilitating factor, even for those who have minimal physical restrictions, and is one of the leading causes for people leaving the workforce.
  2. Heat intolerance in MS is a temporary worsening of symptoms with elevated body temperatures including hot and humid weather, exercising, sunbathing, or fevers. A small rise in body temperature (a quarter to a half a degree) can cause increased fatigue, tingling, blurry vision, or even the inability to walk. Most people living with MS have to avoid outdoor activity and/or use cooling garments to complete simple, daily activities due to this intolerance.
  3. Cognitive dysfunction affects high-level brain functions such as memory, attention/concentration, the ability to solve daily problems, understand and use language, and process information from different senses. Impaired cognition affects 50-65 percent of those living with MS and is another major reason for leaving the workforce early.
  4. Pain/abnormal sensation is a common symptom with MS and can be directly related to neuropathic pain (the disease process itself) or from musculoskeletal pain (changes to the body and immobility). The pain experience is unique to each person and can greatly limit his or her ability to participate in and enjoy socialization and activities. Those living with MS can also experience various abnormal sensations such as numbness and tingling, prickling, sharp/stabbing pains, hot/cold sensations, and burning pains which can also impact movement and daily function.
  5. Depression comes in various forms and can be one of the most common symptoms in MS, more common in people with MS than the general population. Depression can happen to anyone at any time during the disease course and does not correlate to disease severity, however it can greatly impact someone’s quality of life and ability to participate in daily activities.

COMPLICATIONS

People with multiple sclerosis may also develop:

  • Muscle stiffness or spasms
  • Paralysis, typically in the legs
  • Problems with bladder, bowel or sexual function
  • Mental changes, such as forgetfulness or mood swings
  • Depression
  • Epilepsy

DIAGNOSTIC EVALUATION

  • There is no definitive test for MS.
  • Detailed history of episodes of neurologic dysfunction
  • Physical examination.

Other tests include:-

  • CSF evaluation (for presence of IgG antibody or oligoclonal bonding)
  • Evoked potentials of optic pathways & auditory system to assess presence of slowed nerve conduction.
  • MRI of brain and spinal cord (to determine the presence of MS plaques)
  • CT scan (to detect areas of demyelination, but with less detail as by MRI).

MEDICAL MANAGEMENT

• No exact cure.

• Aim is to prevent or postpone the long term disability (often evolves slowly over many years).

• The treatment falls into 3 categories:-

1. Treatment of acute relapses.

2. Treatment aimed at disease management.

3. Symptomatic treatment.

1. Treatment of acute relapse:-

  • Corticosteroid therapy ( anti-inflammatory & immunosuppressive property )
  • For example:
  • Methyl-prednisolone , (given I.V. or orally)
  • Azathioprine & cyclophosphamide (in severe cases)

2. Treat exacerbations:- (treatment aimed at disease management)

  • Interferon-Beta 1b
    • Betaseron, given subcutaneously. (antiviral & immuno-regulatory) (For ambulatory clients with relapsing –remitting).
  • Interferon Beta 1a
    • Avonex, (for treating replasing form of MS).
  • Glatiramer acetate
    • Copaxane, (for relapsing re-emitting MS).

3. Symptomatic treatment:-

  • For bladder dysfunction:
    • oxybutynin, propantheline.
  • For constipation:
    • psyllium hydrophilic mucilloid, suppositories.
  • For fatigue:
    • amantadine, modafinil .
  • For spasticity:
    • baclofen, diazefen, dantrolone.
  • For Tremor :
    • propanolol, phenobarbital, clonazepam.
  • For dysesthesias & trigeminal neurolgia:
    • carbamazepine, phenytoin, amitriptyline.
  • For dysesthesias:
    • Transcutaneous electrical nerve stimulation (TENS) is also helpful.

4. Nutritional therapy:-

  • Megavitamin therapy (cobalamin/vit. B12 and vit. C)
  • Low fat diet.
  • high roughage diet (to relieve constipation)

5. Other therapies:- (to improve neurological functioning)

  • Physical and speech therapies.
  • Exercise.
  • Water exercise.

SURGICAL MANAGEMENT

  • Deep brain stimulation:-
    • if other options have failed then a device is implanted that stimulates an area of brain. (in case of severe tremor in limbs).
  • Implantation of a drug catheter or pump:
    • a catheter is placed in lower spinal area to deliver a constant flow of drug like baclofen. (in case of severe pain or spasticity).

NURSING DIAGNOSIS:

    • Impaired physical mobility related to fatigue & weakness
    • Activity intolerance r/t weakness, dizziness, and unsteady gait
    • Self-esteem disturbance r/t loss of health & lifestyle changes

NURSING MANAGEMENT

    1. Promotes physical mobility – activity and rest
  • no vigorous physical exercise
  • frequent rest periods
  • walking and gait exercises
  • minimize spasticity and contractures – warm packs, daily muscle stretching
  • activities: swimming, stationary bike, progressive wt bearing
  • Minimize effects of immobility; skin integrity; cough and deep breathing exercises.
    1. Prevent injury – walk with feet wide apart, environment awareness and modification, gait training. Use of assistive devices – walker, cane etc.
    2. Promote bladder & bowel control – Urinal/bedpan readily available, po fluids intake schedule/voiding schedule, increase fiber in diet, intermittent self-catheterization
    3. Improve sensory and cognitive function:
  • Vision – eye patch for diplopia; prism glasses for reading; talking books
  • Speech – slurred, low volume, problems with phonation – speech therapist
  • Cognitive & emotional responses – forgetfulness, easily distracted, emotionally labile, social activities; hobbies.
    1. Development of coping strengths – education about diseases process; stress relief; network of services – social, speech, PT, psychological, homemaker/meal on wheels
    2. Improve self-care – assistive devices, raised toilet seat, shower bench, reached tongs, decrease physical and emotional stress, decrease exposure of extreme temperatures
    3. Adapting to sexual dysfunction – counseling, plan sexual activity, willingness to experiment.

Pediatrics Nursing Paper/MCQs

Basis of Pediatrics Nursing

Student Name: ___________S/O_____________ Roll No: ________

Maximum Marks: 100   Passing Marks: 50  Time: 3 Hours Date:

A. OBJECTIVE SECTION

MCQs

Note: Circle the one best answer.

  1. Which cell type is responsible for the early asthmatic response?
    1. Basophil
    2. Eosinophil
    3. Mast cell
    4. Neutrophil
  2. Congenital cyanotic heart disease includes:
    1. VSD.
    2. Patent Ductus Arteriosus.
    3. Fallot tetralogy.
    4. ASD
  3. Fallot tetralogy include:
    1. Pulmonary stenosis
    2. Ventricular septal defect
    3. Over riding aorta
    4. All of the above
  4. Serious complications of Fallot tetralogy includes
    1. Eisenminger syndrome
    2. Recurrent pneumonia
    3. Brain abscess
    4. Pulmonary hypertension
  1. Major manifestations of Rheumatic fever include all the following, Except:
    1. Carditis
    2. Arthralgia
    3. Chorea
    4. Erthema nodosa
  2. All the following are true about acute bronchiolitis, Except:
  • Most cases are under two years old.
  • Most cases are caused by respiratory syncytial virus.
  • Antibiotics are recommended in infants below three months age.
  • Steroids maybe helpful in some cases.
  1. Bronchial asthma is characterized by all the following, Except:
  • Hyper active air way
  • Clubbing
  • Spasmodic cough
  • Bilateral chest wheezes
  1. All of the following cause acute wheezing, Except:
  • Bronchitis
  • Bronchiolitis
  • Bronchiaectasis
  • Bronchial asthma
  1. All of the following are common causes of bacterial pneumonia, Except:
  • Staphylococci.
  • Hemophillus influenza.
  • Pseudomonas.
  • Klepsiella.
  1. All of the following are common causes of empyema, Except:
  • Staphylococcal pneumonia
  • Lung abscess
  • Measles
  • Chest injury
  1. The organ of gas exchange in the fetus is the
    1. Amniotic fluid
    2. Umbilical cord
    3. Placenta
    4. Lungs
  2. Commonest cause of bacterial pneumonia in infancy:
    1. H.. influenza
    2. Streptococcus
    3. Staphylococcus
    4. Pneumococcus
  3. Serious complications of staphylococcal pneumonia include all the following Except :
    1. Lung abscess
    2. Bronchitis
    3. Empyema
    4. Lung collapse
  4. Asthma triggers include all the following Except :
    1. Viral respiratory infections
    2. Tobacco smoke
    3. House dust mite
    4. Steroids
  5. Which of the following statement is not true about Breast milk
  • It contains carbohydrates  7.0 gm %.
  • It contains proteins  4.0 gm %.
  • It contains water 87.5 %.
  • It contains less calcium than cow milk.
  1. Non nutritional marasmus may be caused by.
  • Acute gastroenteritis.
  • Staphylococcal pneumonia.
  • V.S.D.
  • Urinary tract infections
  1. All the following are causes vitamin D deficiency rickets, Except:
  • Low calcium in diet.
  • Prolonged breast feeding
  • Lack of sun exposure.
  • Non response of bone receptors to vitamin D
  1. Colostrum is privileged by having.
  • High iron.
  • High antibodies.
  • High vitamin D.
  • High calcium
  1. The important reflex necessary for breast feeding:
  • Moro reflex
  • Grasp reflex
  • Rooting reflex
  • Cough reflex
  1. The clinical signs of kwashiorkor include the following, Except:
    1. Edema
    2. Skin changes
    3. Hair changes
    4. Bone changes
  2. The complications of rickets include all of the following, Except:
    1. Tetany
    2. Tetanus
    3. Respiratory infection
    4. Fractures
  3. Breast milk contains all of the following nutritional constituents, Except:
    1. 7.2 gm fats
    2. l.2 gm proteins
    3. 7.0 gm carbohydrates
    4. 87.5% water
  4. A fourth degree marasmus infant is characterized by .
    1. Loss of buccal pad of fats.
    2. Skin changes
    3. Edema.
    4. Bowed legs
  5. Breast milk contains all of the following nutritional constituents, Except:
    1. 3.5 gm fats
    2. 1.2 gm proteins
    3. 3.5gm carbohydrates
    4. 87.5% water
  6. Recommended basic requirement of vitamin D for infants is:
    1. 400 u Ikg
    2. 800 ulkg
    3. 200 ulkg
    4. 100 u/kg
  7. Breast milk in the first three days after delivery shows all the following, Except:
    1. Called colostrum
    2. Rich in proteins
    3. High vitamin K content
    4. High caloric value
  8. The clinical signs of kwashiorkor include the following except
    1. Edema
    2. Skin changes
    3. Hair changes
    4. Bone changes
  9. Colostrum is Breast milk secreted in the first post-natal :
    1. 2-3 days
    2. One week.
    3. 3-5 days
    4. One month
  10. Which of the following is not a compulsory vaccine given in the first year of life:
    1. Measles Vaccine.
    2. BCG Vaccine.
    3. Meningitis vaccine.
    4. Polio vaccine.
  11. All the following infectious diseases are essentially associated with rash, Except:
    1. German measles.
    2. Chickenpox.
    3. Mumps.
    4. Roseola infantum
  12. The incubation period of chickenpox is:
    1. One week
    2. 2 to 3 weeks
    3. 2 to 3 months
    4. 3 days
  13. Oral polio vaccine is.
    1. Live attenuated vaccine.
    2. Killed vaccine.
    3. Given at birth.
    4. Given at 4,8,12 months of age
  14. Paroxysmal stage of pertussis persists for:
    1. 2 weeks
    2. 4 weeks
    3. 3 weeks
    4. 8 weeks
  1. The incubation period of measles is :
    1. 2 weeks
    2. 4 weeks
    3. 3 weeks
    4. 8 weeks
  2. The incubation period of Chickenpox is :
    1. 3 weeks
    2. 4 weeks
    3. 8 weeks
    4. 1 week
  3. Rash of measles is characterized by all the following Except:
    1. Starts behind the ears.
    2. Spread from above downwards
    3. May be hemorrhagic in immunocompromised children
    4. May be vesicular
  4. The manifestations of rubella syndrome include the following except
    1. Mental retardation
    2. Microcephaly
    3. Cardiac defects
    4. Macrocephaly
  5. The virus causing chicken pox
    1. Rubella
    2. Varicella
    3. Herpes simplex
    4. None
  6. Paroxysmal stage of pertussis persists for :
    1. 2 weeks
    2. 3 weeks
    3. 4 weeks
    4. 6 weeks
  7. Measles rash begins :
    1. On chest and back
    2. Behind ear
    3. Behind neck
    4. On the face
  8. Complications of diphtheria include all the following Except :
    1. Squint
    2. Flaccid paraplegia
    3. Heart failure
    4. Ataxia
  9. The most common cause of hypovolemic shock is .
    1. Acute renal failure.
    2. Heart failure.
    3. Gastro enteritis.
    4. Toxic. coma
  10. The most common cause for recurrent abdominal pains in children is.
    1. Renal stones.
    2. Familial Mediterranean fever
    3. Intestinal parasites.
    4. Inflammatory bowel disease.
  11. Serious complications of gastroenteritis include:
    1. Dehydration
    2. Acidosis
    3. Shock
    4. All of the above
  12. Hypertonic dehydration is characterized by:
    1. Moist tongue
    2. Lost skin elasticity
    3. High serum sodium
    4. Drowsiness
  13. All of the following are correct about physiological jaundice, Except:
    1. It is a conjugated hyperbilirubinemia
    2. The baby looks healthy and feeds well
    3. Doesn’t exceed 12 mg/dl
    4. It doesn’t persist more than 7 days
  14. All of the following are true about phototherapy, Except:
    1. Reduce serum unconjugated bilirubin level.
    2. Can cause watery stools.
    3. Increase fluid requirement.
    4. Can be a substitute for Exchange transfusion in small preterm with hyperbilirubinemia.
  15. Neonatal period extends up to:
    1. 21 days.
    2. 28 days.
    3. 30 days.
    4. 35 days.
  16. Moro reflex in normal neonates disappear at
    1. 1 week
    2. 3 weeks
    3. 6 weeks
    4. 3 months
  17. The umbilical cord contains
    1. One artery and one vein
    2. One artery and two capillaries
    3. Two arteries and one vein
    4. Two veins and one artery
  18. Persistence of Moro reflex at 12 weeks indicate :
    1. Brain damage
    2. Normal child
    3. Hungry child
    4. Irritable child
  19. Atelectasis due to intra-bronchial obstruction may be due to:
    1. Foreign body
    2. Mucus plug
    3. Both
    4. None
  20. Common presentations of chronic renal failure in children include :
    1. Anemia
    2. Bone deformity
    3. Hypertension
    4. All of the above
  21. The cause of death in spinal polio is:
    1. Paralysis of respiratory muscles
    2. Cardiac arrest
    3. Cranial nerve paralysis
    4. Urinary complications
  22. All of the following might be causes of cerebral palsy ,Except:
    1. Kernicterus.
    2. Toxoplasmosis.
    3. Congenital hypothyroidism.
    4. Tuberous sclerosis
  23. Cerebral palsy is characterized by
    1. Mental retardation
    2. Motor disability
    3. Curable
    4. Sensory loss
  24. The fatal poliomyelitis is :
    1. Bulbar polio
    2. Spinal polio
    3. Encephalitis
    4. Cerebral polio
  25. Delayed puberty may be due to:
    1. Growth hormone deficiency
    2. Malnutrition
    3. Hypothyroidism
    4. All of the above
  26. The site of lesions in myasthenia gravis:
    1. Spinal cord
    2. Neuromuscular junction
    3. Cranial nerves
    4. All of the above
  27. An infant sits without support by….. Month.
    1. 5 month.
    2. 7 month.
    3. 8 month.
    4. 9 month.
  28. The head circumference ,by the end of the second year equals:
    1. 35 cm.
    2. 45 cm.
    3. 50 cm.
    4. 60 cm .
  29. Infants body weight is tripled by the age of:
    1. 5 months
    2. 24 months
    3. 12 months
    4. 18 months
  30. Short stature may be due to:
    1. Growth hormone deficiency
    2. Malnutrition
    3. Hypothyroidism
    4. All the above
  31. An infant supports his head by … … months
    1. 2 months
    2. 4 months
    3. 8 months
    4. 10 months
  32. Weight gain in the first four months of age increase by
    1. 250 gm/month.
    2. 500 gm/ month
    3. 800 gm/ month
    4. 1500 gm/ month
  33. Grasp reflex in normal neonates is present since.
    1. 1 week
    2. 3 weeks
    3. Birth
    4. 3 months
  34. The first deciduous tooth appears by
    1. 3-4 months
    2. 4-5 months
    3. 8-9 months
    4. 5-7 months
  35. The faster weight gain is seen at
    1. First year and puberty
    2. Second year and puberty
    3. Puberty
    4. Infancy
  36. A child starts crawling
    1. 5 months
    2. 7 months
    3. 8 months
    4. 9 months
  37. The average monthly weight gain in the first 4 months :
    1. 250 gm.
    2. 500 gm.
    3. 750 gm.
    4. 1000 gm

B.  Read each statement carefully and circle the correct answer as true or false. (10 Marks)

  1. Humans serve as a reservoir for meningococcal meningitis.
    1. True
    2. False
  2. Currently there is no vaccine for meningococcus.
    1. True
    2. False
  3. Tetanus is nearly always fatal.
    1. True
    2. False
  4. Viral meningitis (“aseptic meningitis”) is usually far more severe and deadly than bacterial or fungal meningitis.
    1. True
    2. False
  5. The common cold is caused by one virus.
    1. True
    2. False
  6. Mycobacterium tuberculosis can survive up to 10 years suspended in fine aerosols.
    1. True
    2. False
  7. Meningitis refers to inflammation of the brain.
    1. True
    2. False
  8. Is meningitis contagious?
    1. True
    2. False
  9. Spina bifida is the deformity of the brain.
    1. True
    2. False
  10. Cleft lip and palate occurs always unilaterally.
    1. True
    2. False

SUBJECTIVE SECTION (20 Marks)

Attempt any five of the following questions. All questions carry equal marks.

Q.No. 01 List the causes of birth defects and explain any one of them: (04 Marks)

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Q.No. 02 Define the Mylomeningocele along with sign and symptoms. (04 Marks)

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Q.No. 03 Write 10 most common accidents of children age with their preventive measures. (04 Marks)

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Q.No. 04 Define tetanus. Explain nursing management of tetanus case. (04 Marks)

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Q.No. 05 Enlist the responsibilities of a pediatric nurse. (04 Marks)

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Q.No. 06 Write down the difference between diarrhea and dysentery. (04 Marks)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Q.No. 07 Define Down Syndrome and elaborate its nursing management. (04 Marks)

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………..THE END………….