question

Risk Factors for RSV

answer

infants and toddlers who are not breastfed, secondary smoke exposure, day care, live in crowded conditions, socioeconomically disadvantaged

question

Tobacco Smoke

answer

increases mucus production and reduces action of the cilia within the airway passages.

question

RSV season

answer

Annual epidemics from October to March.

question

RSV is transmitted...

answer

through direct contact with respiratory secretions or indirectly through contaminated surfaces.

question

Infants at risk for severe RSV

answer

Under 24 mos. w/ chronic luing disease who have required med. therapy w/ in 6 mos. of RSV season onset. Those w/ congentail heart disease, and preterm infants> reduced immunity

question

Risk factors for RSV

answer

Infants and toddlers who are not breastfed, live w/ second smoke, attend daycare, live in crowded conditions, and are socioeconomically disadvantaged.

question

Adult RSV risk factors

answer

Older adults. Chronic pulmonary disease, and CHF

question

Early signs of (mild) RSV

answer

Rhinorrhea (drainable mucus from nose), cough, irritability, low grade fever for 1-3 days

question

Signs of serious RSV

answer

Irratibility, excessive coughing, wheezing, and observable retractions of the ribcage. Nasal flaring, rapid resp. rate, blue skin, listlessness, and periods w/out breathing.

question

RSV Plan of care

answer

Monitoring breathing patterns, maintain patent airway, adequate fluid and caloric intake, support appropriate developmental behavior.

question

Meds. to treat RSV

answer

Ribavirin-controversial-reserved for severe; bronchodialtors-controversial; antipyretics; antiboitics-only if bacteria infection

question

Clinical Therapy for RSV

answer

Isolation. Humidified oxygen using a hood, face tent, mask, or nasal cannula to maintain pulse ox. of greater than 90%. CPAP maybe used w/ moderate-severe.

question

Indication of severe illness in children?

answer

Lack of play. Most children continue to play despite illness.

question

Signs of life-threatening illness

answer

Central cyanosis, resp. rate greater than 70, listlessness, and apneic episodes. The chest is hyperinflated and air exchange is so poor that breath sounds are very diminished on auscultation.

question

Priority nursing care for RSV?

answer

Maintaining a clear airway and promoting oxygenation.

question

Dealing w/ parents?

answer

Include them in providing care, teach interventions-helps reduce their anxiety

question

Stance that indicates resp. distress?

answer

Tripod stance

question

Ineffective Airway Clearance?

answer

Monitor temp, pulse, resp., bp, pulse ox; Auscultate lung sounds; Encourage oral fluids (thin secretions); Suction mouth and nose; Teach parents to suction (bulb syringe), and signs and symptoms, not to smoke; Admin. meds as ordered

question

Ineffective Breathing Pattern?

answer

Monitor breathing pattern-rate, rhythm, and quality; Teach parents to observe breathing patterns; Inspect and palpate chest for use of accessory muscles; Assess for tripod stance; Admin. bronchiodilators and oxygen as ordered

question

Impaired Gas Exchange?

answer

Monitor temp. pulse, resp., bp, and pulse ox; monitor breathing patterns; Assess for bluish skin; Collect sputum specimen; collect ABG, CBC and chem. levels; Admin. oxygen as ordered

question

May indicate increased need for oxygen?

answer

Use of accessory muscles to breath.

question

Bronchiolitis

answer

Lower resp. tract illness that occurs when an infecting agent (virus or bacterium) causes inflammation and obstruction of the small airways (bronchioles)> RSV is most common cause!

question

RSV incubation period

answer

2-8 days. The virus is shed by the infected child for 3-8 days.

question

Atelectasis

answer

Collaspse of alveoli or section of alveoli

question

RSV infects....

answer

the squamous epithelial cells of the bronchioles and alveoli.

question

Syncytia

answer

Large masses of cells created by infected cells merging w/ adjacent cells. Syncytia-burst and die-clogging the minute airways of the lower resp. tract.

question

Wheezing and crackles created by?

answer

Partially obstructed airways allow air in, but the mucus and airway swelling block expulsion of air.

question

RSV Diagnostic Tests

answer

nasopharyngeal culture, chest x-ray

question

Lack of Play

answer

an indication of severe illness in children

question

Signs of life threatening illness in the infant with bronchiolitis include

answer

central cyanosis, RR > 70, listlessness, apneic episodes (periods without breathing), hyperinflated chest, very diminished lung sounds

question

Atelectasis

answer

collapse of alveoli

question

Apnea

answer

absence of respirations

question

The nurse working with a client with Ineffective Airway Clearance should

answer

Monitor vitals, auscultate lung sounds, encourage fluids, suction mouth and nose, teach parents suctioning, teach parents signs ans symptoms, teach parents not to smoke around infant, administer meds

question

The nurse working with a client with an Ineffective Breathing Pattern should

answer

Monitor rate, rhythm and quality of breathing pattern, teach parents how to observe breathing pattern, inspect chest for use of accessory breathing muscles, assess for self posturing, administer bronchodilators and O2 therapy as ordered

question

The nurse working with a patient with Impaired Gas Exchange should

answer

Monitor vitals, monitor breathing patterns, assess for bluish skin color, collect a sputum specimen to i.d. causative agent, collect ABG, CBG, and chemistry levels, admin. O2 as ordered

question

The nurse working with a client with Impaired Nutrition: Less Than Body Requirements should

answer

Monitor dietary intake, take daily weight, offer preferred foods, offer small frequent feedings, encourage parents to feed child as normal

question

Nursing interventions for Fluid Volume Deficit related to fever and poor oral intake include

answer

Assess for poor skin elasticity, dry mucous membranes, and decreased urinary output, weigh each diaper for accurate output, teach parents to count diapers per day, encourage oral intake, monitor IV fluid rate

question

Nursing Interventions for Activity Intolerance include

answer

assessing capacity to play, organize care to allow for rest periods

question

What is the treatment for RSV?

answer

There is no treatment for RSV just it's symptoms

question

What are the treatments for RSV's Symptoms?

answer

Hospitalization, IV fluids, humidified oxygen, bronchodilators, corticosteroids, thin chest secretions, reduce fever

question

How to prevent RSV

answer

cover mouth when cough or sneeze, frequent hand washing with soap and water, avoid sharing cups and utensils, refrain from kissing on the mouth

question

What is the priority of nursing care when taking care of a client with RSV?

answer

Maintaining a patent airway and promoting oxygenation

question

A child in the early stages of impaired gas exchange often experiences which of the following diagnoses as well?

answer

Anxiety related to hypoxia

question

The parents of an infant with bronchiolitis ask the nurse why their baby's room has a sign on the door that says "Contact Precautions" and why all the nurses wear gowns and gloves when they hold him. What is the nurse's best response?

answer

"The virus that usually causes bronchiolitis can spread to other babies if extra precautions are not taken."

question

Which of the following would be a priority nursing intervention for the child with bronchiolitis?

answer

Maintain strict intake and output.

question

The nurse wears gloves when examining a child with respiratory syncytial virus (RSV) infection. After removing the gloves, what should the nurse do next?

answer

Wash hands.

question

A client with hypertension asks the nurse what can be done to relieve the symptoms associated with respiratory syncytial virus (RSV). The nurse recommends which of the following?

answer

Use an over-the-counter nasal spray for no more than 3 days to relieve congestion.

question

The nurse is caring for a 75-year-old client with respiratory syncytial virus (RSV). The nurse monitors this client closely for which of the following?

answer

Pneumonitis

question

The nurse selects Ineffective Airway Clearance for a premature infant who is in the hospital with respiratory syncytial virus (RSV) based on which of the following?

answer

The infant does not have the energy to cough effectively.

question

The nurse is preparing to discharge a frail infant from the nursery to home in October. Which of the following instructions to the parents is a priority? (Select all that apply.)

answer

Keep anyone with a cold away from the infant. Insist that anyone handling the infant use good handwashing. Have the child vaccinated with palivizumab monthly.

question

RSV/Respiratory Syncytial Virus

answer

Respiratory virus that infects the lungs and breathing passages by invading the cells of the bronchial mucosa causing the cells to rupture. This ruptured cell debris irritates the airway leading to increased secretions and airway obstruction.

question

What 2 common illnesses can RSV cause?

answer

Bronchiolitis and Pneumonia

question

What time of year are RSV cases most prevalent?

answer

Fall, Winter, and early Spring

question

Is RSV contagious?

answer

Yes!

question

What precautions level is RSV?

answer

Droplet precautions

question

The most severe cases are in what age group?

answer

Children six months or younger

question

What is the recovery time?

answer

1-2 weeks

question

Can reinfection occur?

answer

Yes!

question

What are the INITIAL symptoms of RSV?

answer

nasal stuffiness, fever, cough, sneeze, decreased appetite, decreased play

question

What are the PROGRESSIVE symptoms of RSV?

answer

deep cough, rapid labored breathing, and respiratory distress such as use of accessory muscles, posturing, sternal retractions, and nasal flaring

question

RSV Assessment Findings

answer

wheezing/crackles upon auscultation, diminished breath sounds upon auscultation, impaired gas exchange, and eventually respiratory failure

question

Who is at risk?

answer

Children <2 with congenital heart disease, premature infants, adults 65 years and older, children and adults with weakend immune systems

question

How is RSV spread?

answer

Droplets (cough or sneeze), Direct (kiss), Indirect (virus on surfaces)

question

What are some common nursing diagnosis for RSV?

answer

Ineffective Airway Clearance, Ineffective Breathing Pattern, Impaired Gas Exchange, Fluid Volume Deficit, Activity Intolerance

question

Chronic Airflow limitation results from these 4 factors?

answer

*Loss of Elasticity, Constricted Airways, Increased (mucous) secretions, Inflammation

question

These 3 common respiratory disorders are characterized by Chronic Airflow Limitation?

answer

*Chronic Bronchitis, Emphysema, Asthma

question

These 5 kinds of medications can be used to treat diseases of limited airflow?

answer

*Bronchodilators, Mucolytics, Antihistamines, Antitussives, Antinflammatories

question

These Liquify and remove secretions?

answer

*Mucolytics

question

Nursing Interventions for clients taking respiratory drugs?

answer

*#1 MAINTAIN AIRWAY, Establish clients baseline respiratory function before admin of meds, Assess clients understanding of meds, expected effects, and safe home useage.

question

Nursing Interventions, Establishing Respiratory Baseline includes assessing?

answer

*Rate, Quality and Auscultation of Breath Sounds, Color of skin and mucous membranes, Activity Tolerance

question

These relax smooth muscle of the bronchi and open narrowed airways (ex:)?

answer

*Bronchodilators such as Albuterol (Proventil), Serevent

question

Expected outcomes after using a Bronchodilator include?

answer

*Decreased Wheezing, Relief of Coughing, Increase in breathing and Increased Activity Tolerance

question

Client teaching for Bronchodilators-seek care IMMEDIATELY if any of these adverse reactions occur?

answer

*Cyanosis, Inability to walk or talk, Lethargy or Confusion, Shortness of Breath, Irregular Heart Rate

question

The action of Anticolinergic Drugs is to?

answer

*Block Acetylcholine (Parasympathetic Neurotransmitter) at the receptor sites

question

This is the most commonly used Anticholinergic/Bronchodilator and can be used in conjunction with Albuterol?

answer

*Atrovent (Ipratropium Bromide)

question

These interrupt the inflammatory process by inhibiting the release of histamine and reduction of edema?

answer

*Glucocorticoids. Some examples are: Prednisone derivitives like Prelone & Deltasone. Others are Flovent, Beclavent, Decadron, Aerobid

question

Glucocorticoids have these 3 important actions?

answer

*Anti-inflammatory, Anti-stress, Anti-allergic

question

Discharge instructions for short term Glucocorticoids should include patient teaching on how to?

answer

Taper off of the drug. Abruptly discontinuing can cause Adrenal Crisis (N&V, Diarrhea, Decreasing LOC, Low BP, Dehydration)

question

These prevent inflammation, edema, brochoconstriction and the release of histamine?

answer

*Mast Cell Stabilizers. The drug of choice for Asthmatics, long term therapy with less side effects than glucocorticoids

question

This is released when the body encounters a foreign agent?

answer

Histamine. Use an Antihistamine (Benedryl) for treatment

question

These thin secretions by changing the molecular composition of mucous, making it thinner, and easily removable?

answer

*Mucolytics (Mucomyst) for treatment of Emphysema and Bronchitis

question

These decrease the adhesiveness of secretions so they can be mobilized and removed from the respiratory tract?

answer

*Expectorants, an example is Robitussin (guaifenesin)*Always give with a full glass of H2O to aid in removal of secretions

question

These suppress coughing in order to promote rest and healing?

answer

*Antitussives, and example is Dextromorphan (Suppress), Tessalon, or Delsym.

question

Chronic Bronchitis

answer

inflammation of the main airways in the lungs.

question

Diaphragmatic/Abdominal breathing

answer

Place one hand on Abdomen and other on chest Inhale concentrating on pushing abdomen out while chest remains still Exhale slowly abdomen moves inward while chest remains still

question

Controlled Coughing Technique

answer

Inhale bronchodilator treatment Cough twice, first to loosen mucus, then to expel it Inhale by sniffing to prevent mucus from moving back to deep airways

question

Huff Coughing

answer

Inhale deeply while leaning forward Exhale sharply with a "huff" sound to help keep airways open while mobilizing secretions

question

Bronchodilators

answer

Relax the smooth muscle of the bronchi and open narrowed airways

question

After administration of Bronchodilators, the nurse expects to see:

answer

Decreased wheezing, Relief of coughing, increased ease in breathing, increase activity tolerance

question

Types of Bronchodilators

answer

Beta-adrenergic agonists, Anticholinergics, Xanthines

question

Beta-adrenergic agonists

answer

cause a sympathetic response (use with caution in pregnant, elderly, clients with: renal dysfunction, hyperthyroidism, prostatic hypertrophy, hypertension, and Glaucoma) Do NOT take any over the counter drugs without consulting physician

question

Examples of Short-acting Beta-adrenergic agonists

answer

Metaproterenol, Albuterol, Terbutaline, Pirbuterol

question

Examples of Long-acting Beta-adrenergic agonists

answer

Serevent, Formoterol

question

Side Effects of Beta-adrenergic agonists

answer

Increased HR, Hyperglycemia, Anxiety, Nervousness/restlessness, and muscle tremors

question

Because of their cardiac effect, Beta-adrenergic agonists would be used with extreme caution in a client with a cardiac disorder. What other disease might contraindicate their use?

answer

Diabetes mellitus

question

The nurse should instruct the client to seek care immediately if any of the following occur while on Beta-adrenergic agonists ...

answer

Cyanosis, increased SHOB, inability to walk or talk, lethargy or confusion, irregular HR

question

Anticholinergics

answer

block parasympathetic response which blocks bronchoconstriction and inflammatory mediators

question

The most common anticholinergic bronchodilator is :

answer

Impratropium bromide (Atrovent)

question

Atrovent

answer

is used in pt.s who do not respond well to beta-a agonists and/or is used along side beta-a agonists. Not useful in treating emergencies, and has greatest therapeutic effect if taken consistently.

question

Anticholinergic Side Effects

answer

Dizziness, headaches, excitemnt, cough, urinary retention, dry mouth, irritability, delayed GI motility

question

Nsg. Interventions for clients on Atrovent therapy

answer

frequent oral care to relieve dry mouth and bitter taste, monitor urinary retention

question

Xanthines

answer

Chemically related to caffeine. Dilate the bronchi by relaxing smooth muscle, have long half life and can cause toxicity because of build up in body. React with many other drugs!

question

Most common Xanthines

answer

Truphylline, Theophylline

question

Manifestations of Xanthine Toxicity are:

answer

CNS stimulation: tremors, headache, agitation, seizures GI distress: nausea, vomiting, anorexia Cardiac stimulation: palpitations, tachycardia, dysrhythmias Hyperglycemia and hypokalemia

question

Effective client teaching for Xanthines should include:

answer

Take the medication at the same time every day Drink plenty of fluids to thin secretions Limit caffeine and smoking Learn the manifestations of toxicity Report any manifestations of theophylline toxicity to the health-careprovider immediately

question

Xanthine Side Effects (like that of caffeine)

answer

tachycardia, insomnia, diuresis, restlessness, epigastric pain, nausea, anorexia

question

What is a safe range for Xanthine levels in the blood?

answer

10-20 mcg/ml

question

Severe Xanthine Toxicity

answer

Seizures, Ventricular fibrillation

question

Types of Anti-inflammatories

answer

Glucorticoids and Mast Cell Stabilizers

question

Glucorticoids

answer

hormones produced by the adrenal cortex that reduce edema and the release of histamines in the respiratory system by interrupting the inflammatory process.

question

Common Glucorticoids

answer

Prednisolone (Prelone), Prednisone (Deltasone), Fluticasone (Flovent)

question

3 Important Actions of Glucorticoids

answer

Ant-inflammatory Anti-allergic Anti-stress

question

Contraindications for Glucorticoids

answer

Peptic ulcer disease, severe infections, hepatic dysfunction

question

Glucorticoids Caution

answer

May stunt growth in children if taken long term and may cause osteoporosis in elderly. Long term therapy may cause Cushingoid appearance

question

Side Effects of Glucorticoids

answer

Hypertension: d/t Na+ and H20 retention Peptic Ulcer: decreased gastric mucous Pancreatitis: d/t increased blood glucose levels Osteoporosis: increased excretion of Ca+ Potassium excretion: r/t Na+ retention Hirsutism: d/t hormonal effect Impaired healing: r/t protein catabolism Ecchymoses: r/t capillary fragillity Muscle wasting: d/t protein catabolism...........and much more!

question

Nursing interventions for clients using glucocorticoids include monitoring for:

answer

Hyperglycemia Hypokalemia Emotional changes Muscle weakness Hypertension

question

If glucocorticoids decrease the inflammatory process and also decrease the immune response, what clinical manifestations will the nurse see in the client?

answer

Absence of manifestations of infection

question

Abruptly stopping If glucocorticoids therapy can cause:

answer

An Adrenal crisis!

question

Nurse care plan for glucocorticoids should include teaching the client to

answer

Regulate activity and control stress Avoid aspirin (Bayer) and other medications unless directed by a physician Wear a MedicAlert bracelet Take oral preparations in the morning Restrict foods high in sodium and eat foods high in potassium Take antacids as prescribed Rinse mouth after use

question

If a client is using both a bronchodilator inhaler and a glucocorticoid inhaler, which inhaler should the nurse tell the client to use first?

answer

Bronchodilator because the bronchi need to be open for the anti-inflammatory to enter and be most effective

question

Mast Cell Stabilizers

answer

Prevents edema, inflammation, and bronchoconstriction. Drug of choice for long term therapy because it lacks side effects of glucorticoids.

question

Common Mast Cell Stabilizer

answer

Cromolyn

question

Clients taking mast cell stabilizers should be taught to:

answer

-Recognize that most cell stabilers are not for acute attacks. -Use 15-30 minutes prior to exercise or exposure to cold because this may reduce an ensuing attack. -Recognize manifestations of a worsening asthma attack and call a health-care provider if respiratory distress occurs.

question

Which instruction is appropriate for the nurse to give the client on cromolyn sodium (Intal)?

answer

Use the medication before exercising to avoid an asthma attack.

Unit 1: RSV – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards