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Family structures
- nuclear - mom, dad, children, dual income
- blended - 2 parents, kids from prev. marriages
- extended - parents & relatives
- binuclear - divorced
- polygamous - many wives
- communal/cohabitating - 2 families in 1 home
- single parent
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Duvall's Developmental Theory
- Stage I - married w/no kids
- Stage II - families w/kid(s) <3 yrs old
- Stage III - families with preschoolers aged 3-6 yrs
- Stage IV - families with school age kids
- Stage V - families w/teenagers
- Stage VI - launching stage - children start leaving home
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Family Systems Theory
stressor experienced by one or more members affects the entire family
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Family APGAR
- Adaptation
- Partnership
- Growth
- Affection
- Resolve
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Family Centered Care
- the importance of family is emphasized
- involves families beliefs & customs
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Family Focused Care
health care provider instructs family on what to do
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Erikson's Stages of Development
- Infant - Trust vs Mistrust
- Toddler - Autonomy vs Shame & Doubt
- Preschooler - Initiative vs Guilt
- School Age Child - Industry vs Inferiority
- Adolescent - Identity vs Role Confusion
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Trust vs Mistrust
- birth - 1 year
- mistrust develops when basic needs are not consistently met
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Autonomy vs Shame & Doubt
- 1-3 years
- focus is on the ability to control their bodies themselves and their environment
- important to encourage the child
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Initiative vs Guilt
- 3-6 years
- begin to initiate activities
- develop a conscious and sense of guilt
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Industry vs Inferiority
- school age - 6-12 yrs
- like to do activities where they can complete
- age where kids start to cheat in order to win or complete a task
- learn to compete and cooperate
- job is to make friends & socialize
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Identity vs Role Confusion
- adolescents 12-18 yrs
- preoccupied with how they look and how they are perceived by others
- can develop role confusion when they try to integrate many other roles into their lives
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Conservation
- able to distinguish just because one is bigger doesn't mean it holds more than a fat one
- thinking biggest has more
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Object Permanence
realizing that just because something disapperas its not gone ex. peek-a-boo
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Increased Fluid Needs
- fever
- V/D
- high-output renal failure
- diabetes insipidus
- burns
- shock
- tachypnea
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Decreased Fluid Needs
- congestive heart failure
- renal failure
- head trauma/meningitis (too much fluid increases ICP)
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Signs of dehydration
- dry skin & mucus membranes
- poor skin turgor
- sunken eyes
- depressed fontanel
- gray or ashen color
- rapid and weak pulse
- decreased BP
- oligura
- decreased tears
- irritability
- delayed capillary refill >2-3 seconds
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Weighing Diapers
1 gm = 1 mL
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Gastroenteritis
- group of clinical syndromes manifested by nausea, vomitting & diarrhea
- Rotavirus is leading cause of pediatric gastroenteritis
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Viral Agents
- more common in winter
- Rotavirus most common in children 6-24 months
- Norwalk - common in daycares & cruise ships in ice & seafood
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Bacterial Agents
- more common in summer
- most recover w/o treatment
- salmonella
- shigella
- e-coli
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Hypernatremia in Dehydration
- warm doughy sin texture
- hypertonia (stiffness)
- hyper-reflexia
- lethargy w/irritability when touched
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Hypokalemia in Dehydration
- weakness
- ileus with abdominal distention
- cardiac arrhythmias
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Management of Gastroenteritis
- assess dehydration
- oral rehydration - avoid carbonated beverages
- normal diet as soon as possible
- continue to breast feel
- protect skin from breakdown
- anti-diarrheal meds discouraged
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Hirschsprung's Disease
- congenital aganglionic megacolon
- absence of parasympathetic ganglion cells in the colon
- peristalsis is normal
- results in obstruction and dilation of the bowel
- fecal mass palpable
- infant fails to pass meconium
- surgically remove aganglionic portion
- surgical emergency if bowel perforates
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Gastroesophageal Reflux (GER)
- gastric contents flow back into esophagus
- failure of the sphincter at the junction of the esophagus and the stomach
- GERD - GER with complications
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S/S of GI Reflux
- spitting up
- vomiting
- weight loss
- gagging, choking at the end of feedings
- respiratory problems
- heartburn
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Diagnostic Testing for GI Reflux
- pH probe
- swallow study
- endoscopy
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Management of GI Reflux
- change to soy formula
- frequent burping
- small feedings < 30 minutes
- elevate HOB
- lay on right side after feeding
- thicken formula with rice cereal
- monitor weight
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Meds for GI Reflux
- H2 Blockers: cimetidine, ranitidine, famotidine
- Proton pump inhibitors - omeprazole, lanzoprazole
- increase gastric emptying - Reglan, erythromycin
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Surgical management of GI Reflux
- Nissen Fundoplication - fundus of stomach is wrapped around lower end of esophagus
- G-Tube
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Inflammatory Bowel Disease
- 2 distinct disorders that invole inflammation of the GI tract:
- ulcerative colitis
- Crohn's Disease
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Crohn's Disease
- cobblestoned lesions
- can occur anywhere in the GI tract
- moderate diarrhea
- significant growth retardation
- NO rectal bleeding
- greatly increased risk of cancer
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Ulcerative Colitis
- continuous superficial lesions on the mucosa
- involves rectum and distal colon
- severe diarrhea
- little growth retardation
- slight increased risk of cancer
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Management of IBD
decrease inflammation
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Management of IBD
- decrease inflammation
- high protein, high calorie, low fiber diet
- surgery: removing diseased colon cures UC
- ileo pouch
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Surgical management of Crohn's
only to manage complications - ulcerations can reoccur
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Cleft Lip and Cleft Palate
- noted on ultrasound 14-16 weeks
- lip repaired with cheiloplasty
- feeding, speech & hearing affected w/cleft palate
- ESSR: Elevate & Enlarge nipple, Stimulate sucking, Swallowing upright, Rest (limit feedings to 30-40 minutes)
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Post-op care after cleft palate repair
- watch for respiratory difficulties
- no sharp objects in mouth
- crying will alter suture line
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TE Fistula and Esophageal Atresia
- TE Fistula: trachea and esophagus fail to separate, they open into each other
- Esophageal Atresia: esophagus doesn't develop fully, just ends
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Management of TE Fistula
- g-tube for feeding
- surgical repair
- suction to remove mucus that could be inhaled
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Pyloric Stenosis
- obstruction of the circular muscle of the pyloris
- palpable pyloric - "olive mass"
- projectile vomiting; no where for food to go
- pyloris (lower part of stomach) narrows so food doesn't leave stomach
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Intussusception
- bowel folds into itself like a collapsed telescope
- abrupt onset, pain
- "current jelly" diarrhea
- mass in RUQ
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Volvulus
- twisting of the intestine
- surgical emergency
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Acute Appendicitis
- inflammation of the appendix
- peritonitis if ruptures
- McBurney point pain
- Rovsing sign: pain in RLQ when any part of abdomen is palpated
- if ruptures: sudden relief of pain
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Biliary Atresia
- blockage or lack of the common bile duct
- does not cause kernicterus-liver still functions to conjugate bilirubin and once conjugated it can't cross BBB
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S/S of Biliary Atresia
- jaundice
- pale stool and dark urine (no bile in intestines)
- pruritis from jaundice
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Management of biliary atresia
- ksasi procedure to make a biliary tree
- vitamin K to manage bleeding
- cholestyramine to control itching
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Short Bowel Syndrome
- malabsorption due to decreased bowel
- caused by anything that needs surgery and decreases bowel
- vit B12 and fat soluble vitamins given
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Celiac Disease
- gluten sensitivity (wheat, barley, rye & oats)
- digestive disease that damages small intestine & interferes with absorption
- impairs absorption
- gluten causes immune system to destroy the villi so nutrients can't be absorbed
- causes protein deficiency
- delays in getting teeth
- bone density changes due to hypocalcemia
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Diagnosis for Celiac Disease
- fecal fat content measured
- positive response to gluten free diet
- celiac crisis: severe acute episodes of watery diarrhea
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Abdominal Wall Defects
- gastroschisis: protrusion of intra-abdominal contents through a defect in the abdominal wall
- no sac present
- Omphalocele: protrusion of viscera into base of umbilical cord
- sac is covered with peritoneum but no skin
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Pediatric blood gas values
- pH: 7.35 - 7.45
- PO2: 80-100
- PCO2: 35-45
- HCO3: 22-26
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Simple ABG Analysis
- Assess PaCO2
- if PaCO2 is >45 = resp acidosis
- if PaCO2 is <35 = resp alkalosis
- Assess the HCO3
- if HCO3 is >26 = metabolic alkalosis
- if HCO3 is <22 = metabolic acidosis
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Apparent Life Threatening Event
- apnea with change in color, muscle tone and/or choking
- can be caused by child abuse or Munchhausen
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SIDS
- sudden unexplained death of an infant under 12 months
- occurs while sleeping
- using a pacifier helps
- 1st symptom is a cardiac arrest
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Croup Syndromes
- upper airway illnesses caused by swelling of the larynx and epiglottis
- Big 3: epiglotitis, laryngotracheobronchitis, bacterial tracheitis
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Epiglotitis
- swelling of the epiglotits
- life threatening
- progresses rapidly
- DO NOT INSPECT VISUALLY: can cause laryngospasm
- thumb sign on lateral x-ray
- S/S: drooling r/t can't swallow, tripod
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Epiglotitis S/S
- high fever
- appears very ill
- 4 D's: drooling, dysphagia, dysphonia, distressed respiratory effort
- keep trach tray at bedside
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Croup
- afebrile, some inspiratory stridor
- does not appear ill
- viral invasion of upper airway
- abrupt onset usually at night - barking cough
- large amounts of thin secretions
- AP x-ray (anterior to posterior)
- steeple sign on x-ray
- cool mist
- albuterol
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Bacterial Tracheitis
- secondary infection of upper trachea after a viral infection
- croupy cough and stridor
- thick secretions
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Bronchiolitis
- caused by RSV virus
- inflammation of lower respiratory tract causing an obstruction of small airways
- contact precautions
- CPT therapy (clapping on back)
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S/S of Bronchiolitis
- fever
- respiratory distress:
- - tachypnea
- - retractions
- - wheezing
- - prolonged expiration
- - rales
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RSV
- infection of respiratory mucosa
- 2 subtypes: Type B - mild, Type A - more virulent
- forms a layer that impairs cilia function
- occurs in winter from Nov to March
- contracted thru direct contact w/nasal secretions
- viruses can live on surfaces
- no immunity - can be reinfected
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RSV Diagnosis
- based on S/S
- enzyme immune assay
- WBC slightly elevated
- chest x-ray
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Cystic Fibrosis
- inherited autosomal recessive disorder affecting
- both parents are carriers: 25% chance of infected child
- : 50% chance child will be a carrier
- : 25% chance child will be OK
- no cure
- copious amounts of mucus produced
- elevated sweat salts (skin will taste salty)
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Normal Pediatric Blood Values
.................2 years............ 12 years
- RBC's: ......4-4.9 ................4-5.3
- Hct: ...........31-37 ..............34-44
- Hgb: .........10.5-12.7........ 11.2-14.8
- WBC: ........5.3-11.5 .........4.5-10.1
- Platelets: .....204-405....... 165-335
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Polycythemia
- increase in RBC's
- S/S: clubbing of fingers, redness to skin, viscous blood
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RBC's
- reticulocytes: immature red blood cell
- old RBC's rmvd by spleen
- carry surface antigents
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Neutrophils
- 1st responder
- polymorphonucleated (poly's): mature neutrophils, 90%
bands: immature, 10%
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Thrombocytes (platelets)
- very sticky
- live 7-10 days
- release substances that stabilize clots
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Absolute Neutrophil Count (ANC)
- Normal: 1500-7200
- ANC <1000: moderate risk for infection
- ANC <500: severe risk for infection
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Anemia
- decreased number of RBC's
- OR
- decrease in the concentration of hemoglobin
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Iron Deficiency Anemia
- most common type
- vitamin C enhances iron absorption
- babies need an iron supplement after 6 months old
- management: iron fortified formula, iron therapy
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Iron-rich foods
- meats
- beans
- egg yolks
- greens
- dried fruits
- grains & enriched breads & pastas
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Signs of iron overdose
- abdominal pain
- bloody diarrhea
- vomiting
- SOB
- shock
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Sickle Cell Disease
- sickle cell trait = carrier
- sickle cell anemia = has disease
- autosomal recessive
- 50% risk child will be a carrier
- 25% risk child will have disease
- 25% risk child will be health
- RBC's become sickled with any decrease in oxygen
- high calorie, high protein diet
- folic acid & vitamin C supplements
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Screening & Diagnosis of Sickle Cell Disease
- screen all newborns
- sickledex done after 6 months
- hemoglobin electrophoresis
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Factors contributing to sickle cell crisis
- fever
- dehydration
- altitude
- temp extremes
- vomitingemtional distress
- fatigue
- alcohol
- pregnancy
- anything that causes blood to be thicker
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Major types of sickle cell crisis
- vaso occlusive - vessels are occluded by sickled cells
- splenic sequestration - spleen fills w/blood and enlarges, sickled cells get trapped in small blood vessels causing blood to get trapped
- aplastic crises - abnormal drop in reticulocytes
- acute chest syndrome
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Dactylitis
- painful
- swelling of an entire digit
- caused by vaso occlusive crisis
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Hemophilia
- inherited coagulation disorder due to deficiency of clotting factors (lowers clotting ability leading to bleeding)
- Hemophilia A: classic- missing factor 8
- Hemophilia B: Christmas - missing factor 9
- Hemophilia C: factor 11
- **Carrier mom & normal dad will have infected son
- Von Willebrand - asbence of a protein and factor 8
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Splenic Sequestration
- life threatening
- blood pools in the spleen
- S/S: anemia, hypovolemia, shock
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Aplastic Crises
- decreased production and increased destruction of RBC's
- S/S profound anemia, pallor, fatigue
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Hemophilia Lab Findings
- prolonged PT
- prolonged PTT
- normal fibrinogen
- normal platelets
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Anemia management
- no cure
- focuses on replacing factor VIII
- no ASA or Motrin
- prevent bleeding: soft toothbrush, electric razor, no contaqct sports
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Disseminated Intravascular Coagulation (DIC)
- formation of small clots in the blood vessels in the body
- as the clots consume protein & platelets normal coagulation is disrupted leading to bleeding
- the small clots may also disrupt blood flow to organs
- tiny clots damage small vessels
- always a secondary disorder
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DIC Lab findings
- decreased platelets
- prolonged PT & PTT
- FSP is increased
- D-dimer is increased
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Idiopathic Thrombocytopenic Purpura (ITP)
- low platelet count (thrombocytopenia) with no known cause (idiopathic)
- results in bruising (purpura)
- blood doesn't clot because of low number of platelets
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Leukemia
- cancer of blood-forming organs
- ALL - acute lymphoblastic leukemia: cancer of lymphoid cells in the bone marrow and lymphoid organs of the body
- AML - acute myelogenous leukemia: cancer of myeloid cells in the bone marrow which help fight bacteria infections
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Symptoms of ALL
- bone & joint pain
- fever
- fatigue
- petechiae
- repeated infections
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Diagnosis of ALL
- not diagnosed thru blood count
- bone marrow - definitive
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Anemia
- decrease in RBC's
- decrease in hemoglobin
- decrease in volume of packed RBC's
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Assessment for Bleeding
platelet count <20,000 at risk for spontaneous bleeding
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Wilms Tumor
- tumor in kidneys
- don't palpate - can rupture
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Tumor Lysis Syndrome
- metabolic abnormalities that occur when tumor cells breakdown rapidly
- more likely to occur during first chemo treatment
- leads to hyperkalemia, hyperuricemia, hyperphosphatemia and hypocalcemia
- kidneys become overwhelmed and cannot excrete them so the blood levels rise
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Nasopharyngitis
- inflammation of the nasal passages and of the upper pharynx
- occurs with the common cold
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Pharyngitis
- inflammation of pharynx and tonsils
- S/S: sore throat
- diagnosis: throat culture
- treatment: if strep-antibiotic - if strep isn't treated can lead to glomuleral nephritis & rheumatic fever
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Tonsillitis
- treatment same as pharyngitis
- assess for bleeding: excessive swallowing, vomiting bright red blood
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