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DEENT Exam 2 > Lecture 1 Fever/Apap/Respiratory > Flashcards

Lecture 1 Fever/Apap/Respiratory Flashcards

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1
Q

A mother comes into the pharmacy and asks for a recommendation about a thermometer purchase for her child… What questions do ask to make the best recommendation?

A

How old is the child?

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2
Q

How do you measure body temperature of an infant less than four weeks old?

A

Electronic thermometer in the axilla

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3
Q

How do you measure body temperature of a child aged 4 weeks to 5 years old?

A

Electronic thermometer in the axilla
Color change strip thermometer in axilla
Infrared tympanic thermometer

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4
Q

How do you measure body temperature of a child aged greater than 5 years old?

A

Electronic thermometer wherever
Color change strip thermometer in axilla
Infrared tympanic thermometer

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5
Q

What is an electronic probe thermometer?

A

Available for oral, rectal, and axillary measurements.
Uses an electronic transducer to provide reading.
Takes 10-60 seconds.
Comes with disposable covers.
Types: pen or pacificer

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6
Q

What is an infrared thermometer?

A

Tympanic artery or forehead temporal temperature.
Uses infrared technology to detect heat from the arterial blood supply.
Measurement in 5 seconds or less.
Need proper use for accuracy.
Expensive, need batteries.

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7
Q

What is a color change strip thermometer?

A

Adhesive strip contains heat-sensitive liquid crystals that change color to indicate different temperatures.
Temperature changes can affect the color of a liquid crystal over a minute of time.
Least accurate method because it can not detect the changes in core temperature.
Least expensive.

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8
Q

What recommendations should be given to someone who is buying a thermometer?

A

Use appropriate technique.
Wait at least 1 hour after vigorous exercise.
Body temperature should be measured with the same thermometer at the same site over the course of the illness to ensure accuracy.
Read display after manufacturer’s suggest time.

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9
Q

How do you take an axillary temperature measurement?

A

Place a clean disposable probe cover over tip.
Turn on thermometer and wait until it is ready for use.
Place tip of thermometer in armpit. Ensure that armpit is clean and dry. Thermometer must be touching skin, not clothes.
If taking a child’s temperature, hold child close to secure the thermometer under armpit if necessary.
Read and record temperature when temperature beeps.

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10
Q

What are the causes of fever?

A

Idiopathic (unknown cause)
Infectious process (viral, bacteria, fungus, protozoa)
Non-infectious process (malignancies or cancer)
Response to certain drugs (what are the drugs that cause fever? - she said there was a chart in our book but I don’t know what book she is talkin’ ‘bout…)

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11
Q

What is a fever defined as in a child?

A

A core temperature of 100.4 F or greater

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12
Q

What is a fever defined as in an adult?

A

A core temperature of 100 F or greater

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13
Q

What is the body temperature range based on site of measurement?

A 
Rectal 97.9 - 100.4 (Normal) greater than 100.4 fever
Oral 95.9 - 99.5 greater than 99.5
Axillary 94.5 - 99.3 greater than 99.3
Tympanic 96.3 - 100 greater than 100
Temporal 97.9 - 100.1 greater than 100.1
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14
Q

To get a tympanic(rectal measurement) or an axillary measurement form an oral measurement what do you do?

A

Tympanic(rectal) = Add 1 degree to oral

Axillary measurement = Subtract 1 degree from oral

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15
Q

What are symptoms from fever?

A

Headache, diaphoresis(sweating), generalized malaise (tired,lethargic), chills, tachycardia, arthralgia(joint paint), myalgia(muscle pain), irritability, and anorexia.

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16
Q

What are the exclusions for self-care for fever?

A

Patients greater than 3 months with rectal temp greater than or equal to 104F.
Children less than 3 months with rectal temp greater than or equal to 100.1F.
Severe symptoms of infection, not self-limiting.
Risk of hyperthermia.
Impaired oxygen utilization (Severe COPD, respiratory distress, heart failure).
Impaired immune function (cancer, HIV)
CNS damage (head trauma, stroke)
Children with a history of febrile seizures or seizure disorders.
Patients greater than 2 with fevers that persist more than 3 days with or without treatment.
Child less than 2 with fevers that persist more than 24 hours.
Child with spots or rash.
Child who refuses to drink fluids.
Child who is lethargic, irritable.
Child who is vomiting and cannot keep down fluids.
Child with repeated diarrhea.

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17
Q

What are the self-treament goals of a fever?

A

To alleviate the discomfort of fever by reducing the body temperature to a normal level.

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18
Q

What are the steps that should be taken if a patient comes in wit a suspected fever?

A

Ask patient/caregiver how body temperature was measured. (If not than offer to take patent’s temperature.).
Obtain symptom information, medical history, allergy information.
See if they have exclusions for self-treatment. (If yes then give medical referral).
Give non drug measures and antipyretic agent.
Discontinue medications after 3 days of treatment (If the patient still has fever than give a medical referral).

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19
Q

What are the non-pharmacologic treatment options for fever?

A

Adequate fluid intake:
Increase by at least 30-60 mL of fluids per hour for children.
Increase by at least 60-120 mL of fluids per hour for adults unless fluids are contraindicated.
Ex: Sports drinks, fruit juice, ice pops. (Caution in those with diarrhea because it may worsen due to sugar)

Lightweight clothing
Remove blankets
Maintain comfortable room temp about 68F

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20
Q

What is the pharmacologic treatment options for fever?

A

Acetaminophen
NSAIDs
Aspirin

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21
Q

What is the mechanism of action for acetaminophen?

A

Analgesic:
Centrally-acting
Inhibition of central prostaglandin synthesis (COX-2) and increase of pain threshold.

Anti-pyretic:
Inhibiting the formation and release of prostaglandins in the central nervous system.
Inhibits endogenous pyrogens at hypothalamus.

Anti-inflammatory:
Minimal properties (usually only used for fever and pain)
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22
Q

What are the dosages for acetaminophen?

A

Adults:
325-650 mg/dose every 4-6 hours
Max: 4g/day

Pediatric:
10-15 mg/kg/dose every 4-6 hours
Max: 5 doses in 24 hours or 75 mg/kg/day

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23
Q

What are the contraindications for acetaminophen?

A

Active and severe hepatic disease.
Hypersensitivity
Severe hepatic impairment.

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24
Q

What are the adverse reactions to acetaminophen?

A

Common: rash/itching, N/V, constipation

Less common: hepatotoxicity (overdose)

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25
What is the pregnancy and lactation category for acetaminophen?
Pregnancy: C(FDA) Lactation: Infant risk minimal
26
What is the dosages for ibuprofen?
Adults: 200-400 mg/dose every 4-6 hours Max: 3.2 g/day Pediatric (MUST BE GREATER THAN 6 MONTHS): 5-10 mg/kg/dose every 6-8 hours Max: 400mg/dose or 40 mg/kg/day
27
What is the dosages for aspirin?
Adults: 325 - 650 mg/dose every 4-6 hours Max: 4g/day Children through the age of 21 years, should not be given aspirin routinely for fever. Especially if fever is associated with a viral illness because it can give them Reyes Syndrome(signs are brain and liver swelling, encephalophy)
28
What are the exceptions in which aspirin may be given to children?
Kawaskai's and Juvinile Idiopathic Arthritis (JIA) disease
29
What are the contraindications to NSAIDs?
Perioperative pain after CABG (Cornary Artery Bypass Graft). | Hypersensitivity
30
What is the black box warning associated with NSAIDs?
Increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke; increased risk of serious GI adverse events, especially in the elderly, including bleeding, ulceration, and perforation of the stomach or intestines.
31
What is the pregnancy category for NSAIDs?
1st and 2nd Trimester: C 3rd Trimester: D Lactation: Enters breast milk / use caution
32
What are the adverse effects of NSAIDs?
``` Common: NAUSEA DYSPEPSIA Anorexia Flatulence Abdominal Pain Rare: Gastric Ulcer Perforation Gastric Obstruction Bleeding Edema Congestive Heart Failure Exacerbation Nephrotoxicity Dizziness Headache Hypersensitivity/Rash Tinnitus ```
33
How long can treatment be for NSAIDs?
3 days before seeking medical attention
34
Why does the American Academy of Pediatrics (AAP) not recommend alternating APAP/Ibuprofen?
Not enough guidance to caregivers about appropriate method of alternation. Monotherapy is usually effective. Increased potential of medication errors with multiple drugs, complexity of regimen, risk of overdose and increased side effects. (The majority of studies show that ibuprofen works better)
35
Fever is self-limiting and rarely poses severe consequences. T/F
True
36
What three was can acetaminophen be metabolized?
``` Gluronidation and Sulfation (90%) Renal excretion (5%) Reactive metabolite that needs Glutathione but if we don't have that then it turns into NAPQI (5%) ```
37
What are the stages of APAP toxicity?
1 - 24 hours Anorexia, nausea, and vomiting 2 - 72 hours Right upper quadrant abdominal pain (common); AST, ALT, and, if poisoning is sever, bilirubin and PT (usually reported as the INR) sometimes elevated. 3 - 96 hours Vomiting and symptoms of hepatic failure; AST ALT, bilirubin, and INR peak; sometimes renal failure and pancreatitis. 4 - 5 days Resolution of hepatotoxicity or progression to multiple organ failure (sometimes fatal)
38
What is NAC?
N-acetylcysteine (Acetadote) is an antidote for APAP overdose introduced in 1974. Oral and IV administration are equally efficacious. Oral and IV NAC administered within 10 hours post APAP ingestion has good outcomes.
39
What is the dosage for IV NAC?
21 hour regimen (3 doses totaling 300 mg/kg) Loading dose: 150 mg/kg infused over 60 minutes 2nd dose: 50mg/kg infused over 4 hours 3rd dose: 100 mg/kg infused over 16 hours
40
What is the oral dose of NAC?
72 hour regimen (18 does totaling 1330 mg/kg) Loading dose: 140 mg/kg Maintenance dose: 70 mg/kg every 4 hours; repeat dose if emesis occurs within 1 hour of administration. Prepare dose with 20% NAC solution in a liquid(Pepsi, grapefruit soda, orange juice) that will mask rotten egg smell. Cover patient with antiemetic therapy.
41
What is the Rumack-Matthew Nomonogram?
A semilogarithmic plot of plasma acetaminophen levels vs time. It is a tool used to stratify patients at risk for hepatotoxicity after a single acute acetaminophen ingestion at a know point in time. A serum concentration is taken after 4 hours and before 24 hours after ingestion. Determines whether not NAC is indicated. Patients with delayed presentation at an unknown time or duration of ingestion, ingestion of ER preparation, or a repeated supratheraputic ingestion cannot be risk stratified with this nomogram.
42
What are the guidelines for using NAC with the Nomogram for acute toxicity?
Administer NAC to acute acetaminophen overdose patients with either possible or probable risk for hepatotoxicity as determined by the nomogram to reduce the incidence of sever hepatotoxicity and mortality, ideally within 8 to 10 hours post ingestion. Do not administer NAC to acute acetaminophen overdose patients with no risk for hepatotoxicity as determined by the Rumack-Matthew nomogram.
43
When does acute toxicity occur?
Greater than 150mg/kg has been ingested over 8 hours or less (about 7.5g for adults) Use Nomogram. Adminsted NAC if it is within the 10 hours with antiemetic.
44
If 36 hours has passed since the ingestion of APAP with no side effects, what do you do?
There likelihood of toxicity is unlikely.
45
When does chronic toxicity occur?
Greater than 4 grams ingested per day by adults. No Rumack-Matthew nomogram. Significant hepatotoxicity very unlikely if AST and ALT are normal (less than 50 IU/L) and APAP level less than 10 micro grams/mL Significant hepatotoxicity is possible if AST and ALT are normal but APAP level is greater than 10 microgram/mL. AST and ALT are high regardless of the acetaminophen level. 24 hours later: Significant hepatotoxicity is unlikely if repeated AST and ALT are normal. Significant hepatotoxicity is assumed if repeated AST and ALT are high.
46
What are the guidelines for treating chronic toxicity of APAP?
Level B: Administer NAC to patients with hepatic failure thought to be due to APAP. Level C: Administer NAC to patients who have hepatotoxicity thought to be due to acetaminophen and have a suspected or known APAP overdose, including repeated supra therapeutic ingestions.
47
What is a side effect of IV NAC?
itching
48
What is a cold?
A viral infection of the UPPER respiratory tract. About 1 billion cases of colds in the US each year. Caused by over 200 viruses (rhinoviruses) Self-limiting 7-14 days. Symptoms like cough can linger for up to a month. Transmission: Self-inoculation (touching the nasal mucosa or conjunctiva after contact with the virus) Airborne transmission.
49
Who are at an increased risk for a cold?
``` Higher exposure rates (daycare) Allergic disorders (can't clear viruses) Smoking Sedentary lifestyle Chronic psychological stress (> 1 month) Sleep deprivation: Poor quality sleep ```
50
What is the time for a cold?
1-3 days - Incubation period | Viruses present for 16-18 days.
51
What is the sequence and times of symptoms of a cold?
Day 1 - Sore throat Day 2-3 Nasal symptoms (dominate by day 2 or 3) Clear, thin, watery for the first 2 days Will get thicker and yellow or green in color as cold progresses. As cold resolves it will revert to clear, thin, and watery. Day 4-5 Cough Low grade fever (less than 100F) - anything higher indicates flu or other respiratory infection
52
How do you categorize a cough?
Acute: Lasting less than 3 weeks (focus on upper respiratory infection) - only one appropriate for self-care Subacute: Lasting 3 - 8 weeks Chronic: Lasting greater than 8 weeks
53
What is influenza?
Caused by a highly contagious viral disease (Orthomyxoviridae family) Viruses A and B cause disease in humans. Incubation period is 1-4 days. Transmisstion can be aerosol or direct contact and can occur as long as the infected person is shedding the virus which is usually 1 day prior to symptoms and 7 days(adults) or 10 days(children) after onset.
54
What are the exclusions for self-treatment of upper respiratory viral illness?
Fever greater than 101.5 Chest pain Shortness of breath Worsening symptoms or additional symptoms Concurrent underlying chronic cardiopulmonary disease (asthma, COPD, HF) Aids or immunosuppressant therapy. Frail patients of advanced age. Hypersensitivity to recommended OTC medications. Infants less than 9 months of age (No cold products if less than 4 years of age)
55
What are the exclusions for self-treatment of acute cough?
``` Cough with thick yellow sputum or green phlegm (use clinical judgement, may be lung infection, generally if it is from the nose it is ok). Fever greater than 103. Chest pain Shortness of breath Cough greater than 7 days Worsening of symptoms or additional symptoms Asthma, COPD, CHF (swollen legs and ankles) Unintended weight loss Drenching nighttime sweats Hemoptysis (coughing up blood) Foreign object aspiration Suspected drug associated cough. ```
56
What is rhinitis?
``` Inflammation of the mucous membranes of the nose. Non-Allergic: Infectious Vasomotor Rhinitis medicamentosa Hormonal (Ex:due to pregnancy) Antaomical Allergic: Intermittent (seasonal) allergic rhinitis Persistent (Perennial) allergic rhinitis ```
57
What is the difference between allergic rhinitis and allergic conjunctivitis?
Allergic rhinitis: Prominent nasal symptoms Allergic conjunctivitis: Prominent ocular symptoms Occur in conjunction often.
58
What is allergic rhinitis statistics?
Affects 20-30 percent of adults and 40 percent of children.
59
What is the risk factors of allergic rhinitis?
``` Family history of asthma or allergic rhinitis Atopic dermatitis Higher socioeconomic status Positive reactions to skin tests Coexisting conditions: Asthma Rhinosinusitis Nasal polyps Atopic dermatitis ```
60
What are the allergic rhinitis triggers?
``` Indoor environmental allergens: House dust-mites Cockroaches Mold spores Cigarette smoke Pet dander ``` Outdoor environmental allergens: Pollen Mold spores Pollutants (ozone and diesle exhaust particles)
61
What are the common symptoms of allergic rhinitis?
Common: Rhinorrhea, nasal congestion, pruritus, sneezing, watery eyes. Bilateral. Worse upon awaking, improve during the day, worsen at night. ``` Symptoms not associated with allergic rhinitis: Unilateral symptoms Pain Epistaxis Purulent rhinorrhea ```
62
What are allergic rhinitis physical findings?
Allergic salute/nasal crease, ocular conjunctivitis, allergic "shiners", pale blue turninates, clear watery discharge, inflamed nasal mucosa, nasal polyps, nasal drainage in pharynx. Typically cold drainage goes down the throat and allergy drainage goes out the nose.
63
What are the two different types of allergic rhinitis?
Intermittent allergic rhinitis: Seasonal allergic rhinitis Hay fever Symptoms occur less than 4 days per week OR less than 4 weeks. Mild: No impairment in sleep or daily activities Moderate to severe: Impairment to sleep or daily activities. Persistent Allergic Rhinitis: Perennial allergic rhinitis Symptoms occur more than 4 days a week AND more than 4 weeks.
64
What is ARIA?
Allergic rhinitis and impact on asthma
65
What are the exclusions for self-care for allergic rhinitis?
Children less than 12 years (could be asthma)* Pregnant or lactating woman (could be of increased blood flow) * Symptoms of nonallergic rhinitis Symptoms of otitis media, sinusitis, bronchitis, or other infection Symptoms of undiagnosed or uncontrolled asthma, COPD, or other respiratory disorder Moderate-to-severe persistent allergic rhinitis or symptoms unresponsive to treatment Sever or unacceptable side effects of treatment. *unless already diagnosed with allergic rhinitis by PCP
66
What is anaphylaxis?
``` Its very confusing. Everything can happen. 1. Acute onset of symptoms (minutes to several hours). 2. At least one of the following: Respiratory compromise Reduced blood pressure Associated symptom of end organ failure. 3. Two or more of the following: Involvement of skin tissue Respiratory compromise Reduced blood pressure Persistant gastrointestinal symptoms. 4. Reduced bood pressure after exposure to known allergens ```

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