Client uploads

Diet sodas contain dangerous chemical phenylalanine Discussion Diet sodas contain dangerous chemical phenylalanine Discussion Many diet sodas contain warnings that they contain phenylalanine. What is this terrible chemical and why is it so dangerous? Many people refuse to drink diet drinks because of this warning label . Do you agree with these individuals? Explain your position. ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. ADDITIONAL INSTRUCTIONS FOR THE CLASS Discussion Questions (DQ) Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Weekly Participation Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. APA Format and Writing Quality Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition. Use of Direct Quotes I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. LopesWrite Policy For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Late Policy The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. Communication Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Disorders of The Upper Airways Presentation ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Disorders of The Upper Airways Presentation For this assignment you will be able to create an infographic or video presentation. Disorders of The Upper Airways Presentation 1. Select one of the topics below. Disorders of the Upper Airway, (Chapter 28, p. 715) 2. Explore the topic and gather the information needed to teach your fellow learners. 3. Please create these items using infographics ( Canva.com ) or video ( Powtoon.com ). If you would like to use a different media source, please email your Instructor first for permission. attachment_1 Understanding Pathophysiology FIRST CANADIAN EDITION Mohamed Toufic El-Hussein, RN, PhD Associate Professor, School of Nursing Faculty of Health, Community & Education Mount Royal University Calgary, Alberta Kelly Power-Kean, MHS, NP, RN Center for Nursing Studies Memorial University St. John’s, Newfoundland Stephanie Zettel, BN, MN Associate Professor 2 School of Nursing and Midwifery Mount Royal University Calgary, Alberta U.S. AUTHORS Sue E. Huether, MS, PhD Professor Emeritus College of Nursing University of Utah Salt Lake City, Utah Kathryn L. McCance, MS, PhD Professor Emeritus College of Nursing University of Utah Salt Lake City, Utah U.S. Section Editors Valentina L. Brashers, MD Professor of Nursing and Woodard Clinical Scholar Attending Physician in Internal Medicine University of Virginia Health System Charlottesville, Virginia Neal S. Rote, PhD Academic Vice-Chair and Director of Research Department of Obstetrics and Gynecology University Hospitals Case Medical Center William H. Weir, MD, Professor of Reproductive Biology and Pathology Case Western Reserve University School of Medicine 3 28 Alterations of Pulmonary Function in Children Valentina L. Brashers, Sue E. Huether, Mohamed El-Hussein CHAPTER OUTLINE Disorders of the Upper Airways, 725 Infections of the Upper Airways, 725 Aspiration of Foreign Bodies, 727 Obstructive Sleep Apnea Syndrome, 727 Disorders of the Lower Airways, 728 Respiratory Distress Syndrome of the Newborn, 728 Bronchopulmonary Dysplasia, 730 Respiratory Tract Infections, 730 Aspiration Pneumonitis, 733 Bronchiolitis Obliterans, 733 Asthma, 733 Acute Lung Injury/Acute Respiratory Distress Syndrome, 735 Cystic Fibrosis, 735 2164 Sudden Unexpected Infant Death, 737 Alterations of respiratory function in children are influenced by physiological maturation, which is determined by age, genetics, and environmental conditions. Infants, especially premature infants, may present special problems because of incomplete development of the airways, circulation, chest wall, and immune system. A variety of upper and lower airway infections can cause respiratory compromise or play a role in the pathogenesis of more chronic pulmonary disease. Pulmonary dysfunction can be categorized into disorders of either the upper or the lower airways. Disorders of the Upper Airways Disorders of the upper airways can cause significant obstruction to airflow. Common causes of upper airway obstruction in children are infections, foreign body aspiration, obstructive sleep apnea, and trauma. Infections of the Upper Airways Table 28-1 compares some of the more common upper airway infections. TABLE 28-1 Comparison of Upper Airway Infections 2165 Condition Age Onset Acute 6 Usually laryngotracheobronchitis months gradual to 3 years Etiology Pathophysiology Symptoms Viral Inflammation from larynx to bronchi Acute tracheitis 1 to 12 years Abrupt Staphylococcus Inflammation of or aureus upper trachea following viral illness Acute epiglottitis 2 to 6 years Abrupt Haemophilus influenzae, group A streptococci Inflammation of supraglottic structures Harsh cough; stridor; lowgrade fever; may have nasal discharge, conjunctivitis High fever; toxic appearance; harsh cough; purulent secretions Severe sore throat; dysphagia; high fever; toxic appearance; muffled voice; may drool; dyspnea; sits erect and quietly Croup Croup illnesses can be divided into two categories: (1) acute laryngotracheobronchitis (croup) and (2) spasmodic croup.1 Diphtheria can also be considered a croup illness but is now rare because of vaccinations. Disorders of The Upper Airways Presentation Croup illnesses are all characterized by infection and obstruction of the upper airways. Croup is an acute laryngotracheitis and almost always occurs in children between 6 months and 5 years of age, with a peak incidence at 2 years of age. In 85% of cases, croup is caused by a virus, most commonly parainfluenza. Other causes include respiratory syncytial virus (RSV), rhinovirus, adenovirus, rubella virus, or atypical bacteria. The incidence of croup is higher in males and is most common during the winter months. Approximately 15% of affected children have a strong family history of croup.2 Spasmodic croup usually occurs in older children. The etiology is unknown but can be triggered by cold, allergy, or viral infection.2,3 Spasmodic croup develops acutely, usually without fever, and tends to recur. Pathophysiology 2166 The pathophysiology of viral croup is caused primarily by subglottic inflammation and edema from the infection. The mucous membranes of the larynx are tightly adherent to the underlying cartilage, whereas those of the subglottic space are looser and thus allow accumulation of mucosal and submucosal edema (Figure 281). Furthermore, the cricoid cartilage is structurally the narrowest point of the airway, making edema in this area critical. Spasmodic croup also causes obstruction but with less inflammation and edema. As illustrated in Figure 28-2, increased resistance to airflow leads to increased work of breathing, which generates more negative intrathoracic pressure that, in turn, may exacerbate dynamic collapse of the upper airway. The Larynx and Subglottic Trachea. A, Normal trachea. B, Narrowing and obstruction from edema caused by croup. (From FIGURE 28-1 Hockenberry, M.J., & Wilson, D. [Eds.]. [2015]. Wong’s nursing care of infants and children [10th ed.]. St. Louis: Mosby.) 2167 FIGURE 28-2 Upper Airway Obstruction With Croup. Clinical manifestations Typically, the child experiences rhinorrhea, sore throat, and lowgrade fever for a few days, and then develops a harsh (seal-like) barking cough, inspiratory stridor, and hoarse voice. The quality of voice, cough, and stridor may suggest the location of the obstruction (Figure 28-3). Most cases resolve spontaneously within 24 to 48 hours and do not warrant hospital admission. A child with severe croup usually displays deep retractions (Figure 28-4), stridor, agitation, tachycardia, and sometimes pallor or cyanosis. 2168 FIGURE 28-3 Listening Can Help Locate the Site of Airway Obstruction. A loud, gasping snore suggests enlarged tonsils or adenoids. In inspiratory stridor, the airway is compromised at the level of the supraglottic larynx, vocal cords, subglottic region, or upper trachea. Expiratory stridor results from a narrowing or collapse in the trachea or bronchi. Airway noise during both inspiration and expiration often represents a fixed obstruction of the vocal cords or subglottic space. Hoarseness or a weak cry is a by-product of obstruction at the vocal cords. If a cough is croupy, suspect constriction below the vocal cords. (Redrawn from Eavey, R.D. [1986]. Contemp Ped, 3[6]: 79; original illustration by Paul SinghRoy.) 2169 FIGURE 28-4 Areas of Chest Muscle Retraction. Spasmodic croup is characterized by similar hoarseness, barking cough, and stridor. It is of sudden onset and usually occurs at night and without prodromal symptoms. It usually resolves quickly. Evaluation and treatment The degree of symptoms determines the level of treatment. Disorders of The Upper Airways Presentation The most common tool for estimating croup severity is the Westley croup score.4 Most children with croup require no treatment; however, some cases require outpatient treatment. These children usually have only mild stridor or retractions and appear alert, playful, and able to eat. There has been much debate about the most effective outpatient treatments for croup. Humidified air does not improve symptoms in mild to moderate croup.5 Glucocorticoids—either injected, oral (dexamethasone [Dexasone]), or nebulized (budesonide [Pulmicort])—have been shown to improve symptoms.6 The presence of stridor at rest, moderate or severe retractions of the chest, or agitation suggests more severe disease and does require inpatient observation and treatment. For acute respiratory distress, nebulized epinephrine (Adrenalin) stimulates ?- and ?-adrenergic receptors and decreases mucosal edema and airway secretions.7 Oxygen should be administered. Heliox (helium–oxygen 2170 mixture) also can be used in severe cases although it is not yet considered a mainstay of routine treatment. Heliox works by improving gas flow and thus decreasing the flow resistance of the narrowed airway.8 In rare cases, croup and spasmodic croup may require placement of an endotracheal tube. Bacterial tracheitis. Bacterial tracheitis (pseudomembranous croup) is the most common potentially life-threatening upper airway infection in children. It is most often caused by Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus [MRSA] strains), Haemophilus influenzae, or group A beta-hemolytic Streptococcus (GABHS). Treatment of viral croup with corticosteroids has increased the risk for bacterial tracheitis. The presence of airway edema and copious purulent secretions leads to airway obstruction that can be worsened by the formation of a tracheal pseudomembrane and mucosal sloughing. Bacterial tracheitis is treated with immediate administration of antibiotics and endotracheal intubation to prevent total upper airway obstruction.9 Acute Epiglottitis Historically, acute epiglottitis was caused by Haemophilus influenzae type b (Hib). Since the advent of H. influenzae vaccine, the overall incidence of acute epiglottitis has been reduced; however, up to 25% of epiglottitis cases are still caused by Hib, which is now more common in adults.10 Current cases in children usually are related to vaccine failure or are caused by other pathogens. Pathophysiology The epiglottis arises from the posterior tongue base and covers the laryngeal inlet during swallowing. Bacterial invasion of the mucosa with associated inflammation leads to the rapid development of edema, causing severe, life-threatening obstruction of the upper airway.10 Clinical manifestations In the classic form of the disease, a child between 2 and 7 years of age suddenly develops high fever, irritability, sore throat, 2171 inspiratory stridor, and severe respiratory distress. The child appears anxious and has a voice that sounds muffled (“hot potato” voice). Drooling, absence of cough, preference to sit, and dysphagia (inability to swallow) are common.11 In addition to appearing ill, the child will generally adopt a position of leaning forward (tripoding) to try to improve breathing. Death can occur in a few hours. Pneumonia, cervical lymph node inflammation, otitis, and, rarely, meningitis or septic arthritis may occur concomitantly because of bacterial sepsis. Evaluation and treatment Acute epiglottitis is a life-threatening emergency. Disorders of The Upper Airways Presentation Efforts should be made to keep the child calm and undisturbed. Examination of the throat should not be attempted because it may trigger laryngospasm and cause respiratory collapse. With severe airway obstruction, the airway may be secured with intubation, and antibiotics are administered promptly. Racemic epinephrine and corticosteroids may be given until definitive management of the airway can be achieved.12 Resolution with treatment is usually rapid. Postexposure prophylaxis with rifampin (Rifadin) is recommended for all household unvaccinated contacts after a child is diagnosed. Tonsillar Infections Tonsillar infections (tonsillitis) are occasionally severe enough to cause upper airway obstruction. As with other infections of the upper airway, the incidence of tonsillitis secondary to GABHS and MRSA has risen in the past 15 years. Upper airway obstruction because of tonsillitis is a well-known complication of infectious mononucleosis, especially in a young child. Tonsillitis may be complicated by formation of a tonsillar abscess, which can further contribute to airway obstruction. Peritonsillar abscess is usually unilateral and is most often a complication of acute tonsillitis.13 The abscess must be drained and the child given antibiotics.14 The development of significant obstruction in tonsillar infections may require the use of corticosteroids, especially in the case of mononucleosis. The management of severe bacterial tonsillitis requires the use of antibiotics. Some children with recurrent tonsillitis benefit from adenotonsillectomy.15 2172 Aspiration of Foreign Bodies Aspiration of foreign bodies (FBs) into the airways usually occurs in children 1 to 4 years of age. More than 100 000 cases and 100 deaths occur each year.16 Most objects are expelled by the cough reflex, but some objects may lodge in the larynx, trachea, or bronchi. Large objects (e.g., hard candy, a bite of hotdog, nuts, popcorn, grapes, beans, toy pieces, fragments of popped balloons, or coins) may occlude the airway and become life-threatening. Items of particular concern would be batteries and magnets. The aspiration event commonly is not witnessed or is not recognized when it happens because the coughing, choking, or gagging symptoms may resolve quickly. FBs lodged in the larynx or upper trachea cause cough, stridor, hoarseness or inability to speak, respiratory distress, and agitation or panic; the presentation is often dramatic and frightening. If the child is acutely hypoxic and unable to move air, immediate action such as sweeping the oral airway or performing abdominal thrusts (formerly called the Heimlich manoeuvre) may be required to prevent tragedy. Otherwise, bronchoscopic removal should be performed urgently. If an aspirated FB is small enough, it will be transferred to a bronchus before becoming lodged. If the FB is lodged in the airway for a notable period of time, local irritation, granulation, obstruction, and infection will ensue. Thus children may present with cough or wheezing, atelectasis, pneumonia, lung abscess, or blood-streaked sputum. These children are treated by prompt bronchoscopic removal of the object and administration of antibiotics as necessary.17 Obstructive Sleep Apnea Syndrome Obstructive sleep apnea syndrome (OSAS) is defined by partial or intermittent complete upper airway obstruction during sleep with disruption of normal ventilation and sleep patterns. Disorders of The Upper Airways Presentation Childhood OSAS is common, with an estimated prevalence of 2 to 3% of children 12 to 14 years of age and up to 13% of children between 3 and 6 years of age.18,19 Prevalence is estimated to be two to four times higher in vulnerable populations (Blacks, Latin Americans, and preterm infants).18 In children, unlike adults, OSAS occurs equally among girls and boys. Possible influences early in life may include passive smoke inhalation, socioeconomic status, and 2173 snoring together with genetic modifiers that promote airway inflammation. Pathophysiology Reduced airway diameter and increased upper airway collapsibility are the common causes of OSAS. Obstruction of the upper airway during sleep results in cyclic episodes of increasing respiratory effort and changes in intrathoracic pressures with oxygen desaturation, hypercapnia, and arousal. The child goes back to sleep and the cycle repeats. Adenotonsillar hypertrophy, obesity, and craniofacial anomalies are associated with decreased airway diameter. Infants are at risk because they have both anatomical and physiological predispositions toward airway obstruction and gas exchange abnormalities.20 Reduced motor tone of the upper airways may be seen in neurological disorders, such as cerebral palsy and Down syndrome. Upper airway inflammation and altered neurological reflexes involving respiratory control of upper airway muscles are significant factors in reducing airway diameter. Allergy and asthma may contribute to inflammation, and children who have a history of a clinically significant episode of RSV bronchiolitis in infancy may exhibit altered neuroimmunomodulatory pathways toward inflammation in the upper airway.21 In obese children, current research links OSAS with airway inflammation and elevated levels of C-reactive protein, which also contribute to increased risk for cardiovascular and metabolic disease.22,23 OSAS also may cause pulmonary disease, insulin resistance, and growth failure.24 Clinical manifestations Common manifestations of OSAS include snoring and laboured breathing, sweating, and restlessness during sleep, which may be continuous or intermittent. There may be episodes of increased respiratory effort but no audible airflow, often terminated by snorting, gasping, repositioning, or arousal. Daytime sleepiness/napping is occasionally reported, as well as nocturnal enuresis. There is no correlation between sleep position and OSAS in children, except for those children who are notably obese. Obese children may adopt the prone position to attempt improved ventilation. Cognitive and neurobehavioural impairment, excessive 2174 daytime sleepiness, impaired school performance, and poor quality of life are consequences of OSAS.25 Evaluation and treatment All parents should be asked if their child exhibits snoring, followed by a careful history and physical examination. A variety of screening tools are available. Imaging of the upper airway may be used to rule out adenoidal hypertrophy or upper airway narrowing.26 The most definitive evaluation is the polysomnographic sleep study, which documents obstructed breathing and physiological impairment. Disorders of The Upper Airways Presentation If obstructive sleep apnea is documented or strongly suspected clinically, children are most often referred for tonsillectomy and adenoidectomy (T & A) on the basis of described symptoms and physical findings, such as enlarged tonsils, adenoidal facies, and mouth breathing. For severely affected children who do not respond to T & A or who have different problems, such as obesity, continuous positive airway pressure (CPAP), anti-inflammatories, dental treatments, high-flow nasal cannula, and weight loss can be considered. Treatment is important to minimize associated morbidities.27,28 Quick Check 28-1 1. Compare and contrast pathology, clinical presentations, and severity of croup and epiglottitis. 2. What symptoms indicate aspiration of a foreign body? 3. What signs and symptoms suggest obstructive sleep apnea syndrome? Disorders of the Lower Airways Lower airway disease is one of the leading causes of morbidity in the first year of life and continues to be an important component of other illnesses progressing into childhood. Pulmonary disorders commonly observed include neonatal respiratory distress syndrome, bronchopulmonary dysplasia (BPD), infections, asthma, cystic fibrosis (CF), and acute respiratory distress syndrome 2175 (ARDS). Respiratory Distress Syndrome of the Newborn Respiratory distress syndrome (RDS) of the newborn (previously known as hyaline membrane disease [HMD]) is a significant cause of neonatal morbidity and mortality. It occurs almost exclusively in premature infants, and the incidence has increased in North America over the past two decades.29 RDS occurs in 50 to 60% of infants born at 29 weeks’ gestation and decreases significantly by 36 weeks. Risk factors are summarized in Risk Factors: Respiratory Distress Syndrome of the Newborn. Death rates have declined significantly since the introduction of antenatal steroid therapy and postnatal surfactant therapy. Risk Factors Respiratory Distress Syndrome of the Newborn • Premature birth or low birth weight • Male gender • Caesarean delivery without labour • Diabetic mother • Perinatal asphyxia Pathophysiology RDS is caused by surfactant deficiency, which decreases the alveolar surface area available for gas exchange. Surfactant is a lipoprotein with a detergentlike effect that separates the liquid molecules inside the alveoli, thereby decreasing alveolar surface tension. Without surfactant, alveoli collapse at the end of each exhalation. Surfactant normally is not secreted by the alveolar cells until approximately 30 weeks’ gestation. In addition to surfactant deficiency, premature infants are born with underdeveloped and small alveoli that are difficult to inflate and have thick walls and 2176 inadeq … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Discussion: Turner Syndrome Factsheet ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Turner Syndrome Factsheet Down syndrome Fragile X syndrome Tay-Sachs disease Prader-Willi syndrome Turner syndrome Fetal Alcohol syndrome Prepare a Fact Sheet about the condition you have selected. Your final product should include: a definition/description of the disability, characteristics of the disability, possible causes of the disability (if appropriate), treatment/interventions, and educational implications. Make sure you reference your work. Discussion: Turner Syndrome Factsheet You can google image search : Sample Fact Sheets and Blank Fact Sheet Templates if you need examples if you need. There are A LOT of resources. Plagiarism free with report please know how to make a fact sheet I’m sure there are examples online I’ll try to provide some You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. ADDITIONAL INSTRUCTIONS FOR THE CLASS Discussion Questions (DQ) Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Weekly Participation Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. APA Format and Writing Quality Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition. Use of Direct Quotes I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. LopesWrite Policy For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Late Policy The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. Communication Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Potential effects of bilingual programs on students academic Potential effects of bilingual programs on students academic What are the potential effects of bilingual programs on students’ academic and social success? When reviewing the aforenoted, how would you rate your current academic setting on a scale of 1-10, 10 being the highest, with having these parameters in place? POSSIBLE RESOURCES: – https://education.stateuniversity.com/pages/1788/Bilingual-Education.html ) -Bilingual vs. ESL and Bilingual vs. Dual Language ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS http://eslpartytown.com/bilingual-esl-dual-language.html ”Teaching Diverse Students: Bilingual and English as a Second Language (ESL),” by Hassaen from SAGE Video (2015). (VIDEO TRANSCRIPT)(ATTACHED FILE) -Read ”Bilingual Education in the United States: An Historical Overview and Examination of Two-Way Immersion,” by Kim, Hutchinson, and Winsler from Educational Review (2015).(ATTACHED FILE) Requirements: 500 words Answer preview to what are the potential effects of bilingual programs on students’ academic and social success You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Effective Surveillance Response ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Effective Surveillance Response Responses to classmate colleagues’ initial postings : Read a selection of your classmate’s postings and provide a substantive reply to your colleagues by , in one or more of the following ways, by: (a) expanding on your classmate colleague’s posting; (b) offering an insight from having read your classmate’s posting; (c) corroborating an idea from your own experience; (d) concurring or disagreeing by explaining why with supporting evidence or concepts from the readings or literature; (d) asking a probing question. You must provide response postings to at least three (3) classmate colleagues’ postings. Responses must contain 200–250 words (not including references) and at least 1 reference . References in the response postings will support response statements and assertions; and serve as an additional resource to fellow classmates. Howard University NURS535 Week 12 Effective Surveillance Response Paper please only use the resources attached to do the 3 responses..also please check your APA citations (professor has been complianing) attachment_1 attachment_2 attachment_3 attachment_4 attachment_5 Ashley Pevia Surveillance and Attribution Investigations Collapse Biosurveillance Systems Biosurveillance focuses on developing effective surveillance, prevention and operational capabilities for detecting and countering biological threats. The system works closely with hospitals, health care providers and various laboratories to identify disease cases, investigate the potential spread and guide actions (CLS). The Department of Homeland Security’s Apex Programs is a screening process that look strategically at the nations security and address future biological threats. The Apex Screening at Speed is a program that efficiently screens people for concealed explosive threats (APEX). Created specifically for United States airport TSA, the detection system screens carry on bags and uses X-Ray’s to surveillance further risks. Another example of a biosurveillance system is The Global Biosurveillance Portal. The Biosurveilance Portal is an international system that is mainly focused on coordinating and synchronizing information with international and federal organizations. The system assist in biological defenses by allowing users to organize web applications receives data from various facilities. The data is then taken and analyzed and sent to organizations to development strategies to counter biological threats. Importance of Biosurveillance Biosurveillance is imperative for public health preparedness. The Nation is confronted by an array of health threats with natural, accidental and deliberate origins. Public health professionals are responsible for addressing health on consequences of all types of disaster. Emerging biological threats could wipe out many plant and animal species and could drastically cause a decline in the human population. Biosurveilance for human health includes 3 functional components including detecting baseline disease outbreaks, investigate potential threats and respond when a threat is confirmed. It is important to prepare for biological threats and implementing response measures for adequate communication and counter bioterrorism measures. Michael Enright was an English Actor known for his role in The Pirates of the Caribbean and other popular movies. Michael gave up acting to work towards the fight against bioterrorism. He worked on the field in Syria combating ISIS and he also worked with the U.S immigration system to combat bioterrorism (Franzia, 2019). Policy Directives & Investigations After the Anthrax attack in 2001, new laws aimed to boost public health was proposed. Congress in conjunction with Public Health Security administration proposed the Public Health Security and Bioterroism Prepardness and Response Act of 2002. The bill authorized more than $1.5 billion in grants to develop improved planning, enhanced laboratory capacity, training personnel and prevention efforts. Attribution investigations are conducted through data collection systems. Analyzing data can aid in investigation for biological attacks. The CDC helps various agencies investigate possible terrorist attacks to prevent the country from future harm. Resources Anderson, J. A., Rosenzweig, C. N., Roos, J., & Flores, B. (2015). The Global Biosurveillance Portal: Biosurveillance for the Department of Defense. Online Journal of Public Health Informatics, 7(1), e63. doi:10.5210/ojphi.v7i1.5729 Center for Disease Control, 2010. Biosurveillance: Smart Investments for early Warning. Retrieved from: https://www.cdc.gov/washington/testimony/2010/t20100225.htm Ross, Robert. 2002. New bioterrorism law aims to boost public health, guard food and water. Center for Infectious Disease Research and Policy. Retrieved from: http://www.cidrap.umn.edu/news-perspective/2002/06/new-bioterrorism-law-aims-boost-public-health-guard-food-and-water Franzia. 2019. A British actor left Hollywood to fight ISIS. Now he’s marooned in Belize. The Washington Post. Retrieved from: https://www.washingtonpost.com/lifestyle/2019/10/15/british-actor-left-hollywood-fight-isis-now-hes-marooned-belize-its-quite-story/?arc404=true Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Discuss the respiratory system Discuss the respiratory system Duration: (4:42)User: rtamerica http://www.youtube.com/watch?v=nvBIricsi7E undefined OPTIONAL VIDEO -Closed caption available ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Please type in the Subject line the question number and your topic (so that others won’t duplicate your topic). This will make it easier for other students not to repeat posts. Once an example has been used for a question it cannot be repeated. You will earn zero (0) points if you submitted a repeated topic. Please review the Rubric in the Syllabus to check that you’ve met the requirements. Use spell check and grammar check before posting. undefined In this module, we discuss the respiratory system. Make sure you state the illness, disease, disorder, or poison in the Subject line of your post. If you take three or more words directly from a source, words that are not considered common phrases, you must quote and cite where your information came from. Questions: 1) Respiratory illnesses/disorders are some of the scarier issues one faces when reminded of one’s own mortality . They often cause the feeling of suffocation or being unable to catch one’s breath. State an illness, disease, or disorder. How does it compromise the respiratory system ? What can be done to remedy the situation if there is a remedy? If not, what can be done to make the person more comfortable? undefined 2) Many poisons interfere with the ability of the respiratory system to effectively function. Poisons come in many forms. Some act quickly while others kill after long-term exposure. Some poisons can be inhaled, others injected. Some poisons are only poisons when abused, such as those used during surgery. Name a poison that negatively affects the respiratory system. State how it interferes with the respiratory system specifically and what corrective action can be taken to remedy the negative effects, assuming that it is possible to reverse the effects of the poison. Requirements: 100 words Answer preview to respiratory illnesses/disorders are some of the scarier issues one faces when reminded of one’s own mortality. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Three classic models of the urban spatial structure Three classic models of the urban spatial structure 1. Three classic models of the urban spatial structure are the concentric zone model, the sector model, and the multiple nuclei model. Though simplistic, they are useful for making general observations about urban spatial structures. Review the video attached, summarize and describe the characteristics of these three models. (minimum 200 words) https://youtu.be/AKpe2C7jxC8 2. Though globalization may be considered a unifying force, it has also proven to have a polarizing effect, specifically in large cities. Think about a city(Use NYC) and discuss whether globalization has been more positive or negative for the development of your chosen city. (minimum 250 words) Requirements: 450 Words ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Answer preview to three classic models of the urban spatial structure are the concentric zone model, the sector model, and the multiple nuclei model You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

WNE BME350 Biotransport Processes Problem Set 2 Exercise ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON WNE BME350 Biotransport Processes Problem Set 2 Exercise hello there I will post 5 math and physics questions, it should take you that long. WNE BME350 Biotransport Processes Problem Set 2 Exercise look at it before attachment_1 attachment_2 attachment_3 BME 350 Biotransport Processes Issued: Thursday, January 24, 2019 Due: Tuesday, February 5, 2019 Problem Set #2 PART 1: First Order Differential Equations The function y(t) obeys the differential equation 3 dy?t ? 1 ? y?t ? ? 2u ?1 ?t ? dt 2 for both negative and positive times. Given the initial condition y(0) = 0 you are required to find an expression for y(t) for t > 0. Recall that the function u-1(t) is a unit step function, defined by u-1(t) = 0 ; t < 0 u-1(t) = 1 ; t > 0 or t = 0. i) Write down the differential equation for t > 0. ii) Solve the differential equation in i). iii) Provide a rough sketch of the solution. 1 PART 2: Continuity in three dimensional Cartesian coordinates In three dimensional Cartesian coordinates the continuity equation is of the form ? ?C ?x, y, z, t ? ? ? ? ?x, y, z, t ? ? ? ?t where ? ? ? ? ?x, y, z, t ? ? ? x ?x, y, z, t ?i ? ? y ?x, y, z, t ? ˆj ? ? z ?x, y, z, t ?k and ? ?? ?x, y, z, t ? ?? y ?x, y, z, t ? ?? z ?x, y, z, t ? ? ? ? ?x, y, z, t ? ? x ? ? . ?x ?y ?z Outline a derivation of this equation. PART 3: Exercise 3.18 From Weiss PART 4: Problems 3.1 and 3.2 From Weiss 2 … You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. ADDITIONAL INSTRUCTIONS FOR THE CLASS Discussion Questions (DQ) Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Weekly Participation Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. APA Format and Writing Quality Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition. Use of Direct Quotes I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. LopesWrite Policy For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Late Policy The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. Communication Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. WNE BME350 Biotransport Processes Problem Set 2 Exercise Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Why do you think the role of the editor/reviewer is so critical in ensuring such quality Why do you think the role of the editor/reviewer is so critical in ensuring such quality Topic 4 DQ 1 The credibility and reliability of peer reviewed research communications are seen as the “gold standard” within the basic and applied sciences. Why do you think the role of the editor/reviewer is so critical in ensuring such quality? ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Topic 4 DQ 2 Despite the speed with which electronic manuscripts can be transported and edited with track changes, the peer review process continues to predominantly send copies of original manuscripts by postal mail and the reviewers still use copy editing marks. Why do you suppose this is so? Answer preview to why do you think the role of the editor/reviewer is so critical in ensuring such quality You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

Obstructive Sleep Apnea Syndrome Presentation ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Obstructive Sleep Apnea Syndrome Presentation For this assignment you will be able to create an infographic or video presentation. Obstructive Sleep Apnea Syndrome Presentation 1. Select one of the topics below. Obstructive Sleep Apnea, (Chapter 28, p. 717) 2. Explore the topic and gather the information needed to teach your fellow learners. 3. Please create these items using infographics ( Canva.com ) or video ( Powtoon.com ). If you would like to use a different media source, please email your Instructor first for permission. attachment_1 Understanding Pathophysiology FIRST CANADIAN EDITION Mohamed Toufic El-Hussein, RN, PhD Associate Professor, School of Nursing Faculty of Health, Community & Education Mount Royal University Calgary, Alberta Kelly Power-Kean, MHS, NP, RN Center for Nursing Studies Memorial University St. John’s, Newfoundland Stephanie Zettel, BN, MN Associate Professor 2 School of Nursing and Midwifery Mount Royal University Calgary, Alberta U.S. AUTHORS Sue E. Huether, MS, PhD Professor Emeritus College of Nursing University of Utah Salt Lake City, Utah Kathryn L. McCance, MS, PhD Professor Emeritus College of Nursing University of Utah Salt Lake City, Utah U.S. Section Editors Valentina L. Brashers, MD Professor of Nursing and Woodard Clinical Scholar Attending Physician in Internal Medicine University of Virginia Health System Charlottesville, Virginia Neal S. Rote, PhD Academic Vice-Chair and Director of Research Department of Obstetrics and Gynecology University Hospitals Case Medical Center William H. Weir, MD, Professor of Reproductive Biology and Pathology Case Western Reserve University School of Medicine 3 28 Alterations of Pulmonary Function in Children Valentina L. Brashers, Sue E. Huether, Mohamed El-Hussein CHAPTER OUTLINE Disorders of the Upper Airways, 725 Infections of the Upper Airways, 725 Aspiration of Foreign Bodies, 727 Obstructive Sleep Apnea Syndrome, 727 Disorders of the Lower Airways, 728 Respiratory Distress Syndrome of the Newborn, 728 Bronchopulmonary Dysplasia, 730 Respiratory Tract Infections, 730 Aspiration Pneumonitis, 733 Bronchiolitis Obliterans, 733 Asthma, 733 Acute Lung Injury/Acute Respiratory Distress Syndrome, 735 Cystic Fibrosis, 735 2164 Sudden Unexpected Infant Death, 737 Alterations of respiratory function in children are influenced by physiological maturation, which is determined by age, genetics, and environmental conditions. Infants, especially premature infants, may present special problems because of incomplete development of the airways, circulation, chest wall, and immune system. A variety of upper and lower airway infections can cause respiratory compromise or play a role in the pathogenesis of more chronic pulmonary disease. Pulmonary dysfunction can be categorized into disorders of either the upper or the lower airways. Disorders of the Upper Airways Disorders of the upper airways can cause significant obstruction to airflow. Common causes of upper airway obstruction in children are infections, foreign body aspiration, obstructive sleep apnea, and trauma. Infections of the Upper Airways Table 28-1 compares some of the more common upper airway infections. TABLE 28-1 Comparison of Upper Airway Infections 2165 Condition Age Onset Acute 6 Usually laryngotracheobronchitis months gradual to 3 years Etiology Pathophysiology Symptoms Viral Inflammation from larynx to bronchi Acute tracheitis 1 to 12 years Abrupt Staphylococcus Inflammation of or aureus upper trachea following viral illness Acute epiglottitis 2 to 6 years Abrupt Haemophilus influenzae, group A streptococci Inflammation of supraglottic structures Harsh cough; stridor; lowgrade fever; may have nasal discharge, conjunctivitis High fever; toxic appearance; harsh cough; purulent secretions Severe sore throat; dysphagia; high fever; toxic appearance; muffled voice; may drool; dyspnea; sits erect and quietly Croup Croup illnesses can be divided into two categories: (1) acute laryngotracheobronchitis (croup) and (2) spasmodic croup.1 Diphtheria can also be considered a croup illness but is now rare because of vaccinations. Obstructive Sleep Apnea Syndrome Presentation Croup illnesses are all characterized by infection and obstruction of the upper airways. Croup is an acute laryngotracheitis and almost always occurs in children between 6 months and 5 years of age, with a peak incidence at 2 years of age. In 85% of cases, croup is caused by a virus, most commonly parainfluenza. Other causes include respiratory syncytial virus (RSV), rhinovirus, adenovirus, rubella virus, or atypical bacteria. The incidence of croup is higher in males and is most common during the winter months. Approximately 15% of affected children have a strong family history of croup.2 Spasmodic croup usually occurs in older children. The etiology is unknown but can be triggered by cold, allergy, or viral infection.2,3 Spasmodic croup develops acutely, usually without fever, and tends to recur. Pathophysiology 2166 The pathophysiology of viral croup is caused primarily by subglottic inflammation and edema from the infection. The mucous membranes of the larynx are tightly adherent to the underlying cartilage, whereas those of the subglottic space are looser and thus allow accumulation of mucosal and submucosal edema (Figure 281). Furthermore, the cricoid cartilage is structurally the narrowest point of the airway, making edema in this area critical. Spasmodic croup also causes obstruction but with less inflammation and edema. As illustrated in Figure 28-2, increased resistance to airflow leads to increased work of breathing, which generates more negative intrathoracic pressure that, in turn, may exacerbate dynamic collapse of the upper airway. The Larynx and Subglottic Trachea. A, Normal trachea. B, Narrowing and obstruction from edema caused by croup. (From FIGURE 28-1 Hockenberry, M.J., & Wilson, D. [Eds.]. [2015]. Wong’s nursing care of infants and children [10th ed.]. St. Louis: Mosby.) 2167 FIGURE 28-2 Upper Airway Obstruction With Croup. Clinical manifestations Typically, the child experiences rhinorrhea, sore throat, and lowgrade fever for a few days, and then develops a harsh (seal-like) barking cough, inspiratory stridor, and hoarse voice. The quality of voice, cough, and stridor may suggest the location of the obstruction (Figure 28-3). Most cases resolve spontaneously within 24 to 48 hours and do not warrant hospital admission. A child with severe croup usually displays deep retractions (Figure 28-4), stridor, agitation, tachycardia, and sometimes pallor or cyanosis. 2168 FIGURE 28-3 Listening Can Help Locate the Site of Airway Obstruction. A loud, gasping snore suggests enlarged tonsils or adenoids. In inspiratory stridor, the airway is compromised at the level of the supraglottic larynx, vocal cords, subglottic region, or upper trachea. Expiratory stridor results from a narrowing or collapse in the trachea or bronchi. Airway noise during both inspiration and expiration often represents a fixed obstruction of the vocal cords or subglottic space. Hoarseness or a weak cry is a by-product of obstruction at the vocal cords. If a cough is croupy, suspect constriction below the vocal cords. (Redrawn from Eavey, R.D. [1986]. Contemp Ped, 3[6]: 79; original illustration by Paul SinghRoy.) 2169 FIGURE 28-4 Areas of Chest Muscle Retraction. Spasmodic croup is characterized by similar hoarseness, barking cough, and stridor. It is of sudden onset and usually occurs at night and without prodromal symptoms. It usually resolves quickly. Evaluation and treatment The degree of symptoms determines the level of treatment. Obstructive Sleep Apnea Syndrome Presentation The most common tool for estimating croup severity is the Westley croup score.4 Most children with croup require no treatment; however, some cases require outpatient treatment. These children usually have only mild stridor or retractions and appear alert, playful, and able to eat. There has been much debate about the most effective outpatient treatments for croup. Humidified air does not improve symptoms in mild to moderate croup.5 Glucocorticoids—either injected, oral (dexamethasone [Dexasone]), or nebulized (budesonide [Pulmicort])—have been shown to improve symptoms.6 The presence of stridor at rest, moderate or severe retractions of the chest, or agitation suggests more severe disease and does require inpatient observation and treatment. For acute respiratory distress, nebulized epinephrine (Adrenalin) stimulates ?- and ?-adrenergic receptors and decreases mucosal edema and airway secretions.7 Oxygen should be administered. Heliox (helium–oxygen 2170 mixture) also can be used in severe cases although it is not yet considered a mainstay of routine treatment. Heliox works by improving gas flow and thus decreasing the flow resistance of the narrowed airway.8 In rare cases, croup and spasmodic croup may require placement of an endotracheal tube. Bacterial tracheitis. Bacterial tracheitis (pseudomembranous croup) is the most common potentially life-threatening upper airway infection in children. It is most often caused by Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus [MRSA] strains), Haemophilus influenzae, or group A beta-hemolytic Streptococcus (GABHS). Treatment of viral croup with corticosteroids has increased the risk for bacterial tracheitis. The presence of airway edema and copious purulent secretions leads to airway obstruction that can be worsened by the formation of a tracheal pseudomembrane and mucosal sloughing. Bacterial tracheitis is treated with immediate administration of antibiotics and endotracheal intubation to prevent total upper airway obstruction.9 Acute Epiglottitis Historically, acute epiglottitis was caused by Haemophilus influenzae type b (Hib). Since the advent of H. influenzae vaccine, the overall incidence of acute epiglottitis has been reduced; however, up to 25% of epiglottitis cases are still caused by Hib, which is now more common in adults.10 Current cases in children usually are related to vaccine failure or are caused by other pathogens. Pathophysiology The epiglottis arises from the posterior tongue base and covers the laryngeal inlet during swallowing. Bacterial invasion of the mucosa with associated inflammation leads to the rapid development of edema, causing severe, life-threatening obstruction of the upper airway.10 Clinical manifestations In the classic form of the disease, a child between 2 and 7 years of age suddenly develops high fever, irritability, sore throat, 2171 inspiratory stridor, and severe respiratory distress. The child appears anxious and has a voice that sounds muffled (“hot potato” voice). Drooling, absence of cough, preference to sit, and dysphagia (inability to swallow) are common.11 In addition to appearing ill, the child will generally adopt a position of leaning forward (tripoding) to try to improve breathing. Death can occur in a few hours. Pneumonia, cervical lymph node inflammation, otitis, and, rarely, meningitis or septic arthritis may occur concomitantly because of bacterial sepsis. Evaluation and treatment Acute epiglottitis is a life-threatening emergency. Efforts should be made to keep the child calm and undisturbed. Examination of the throat should not be attempted because it may trigger laryngospasm and cause respiratory collapse. With severe airway obstruction, the airway may be secured with intubation, and antibiotics are administered promptly. Racemic epinephrine and corticosteroids may be given until definitive management of the airway can be achieved.12 Resolution with treatment is usually rapid. Postexposure prophylaxis with rifampin (Rifadin) is recommended for all household unvaccinated contacts after a child is diagnosed. Tonsillar Infections Tonsillar infections (tonsillitis) are occasionally severe enough to cause upper airway obstruction. As with other infections of the upper airway, the incidence of tonsillitis secondary to GABHS and MRSA has risen in the past 15 years. Obstructive Sleep Apnea Syndrome Presentation Upper airway obstruction because of tonsillitis is a well-known complication of infectious mononucleosis, especially in a young child. Tonsillitis may be complicated by formation of a tonsillar abscess, which can further contribute to airway obstruction. Peritonsillar abscess is usually unilateral and is most often a complication of acute tonsillitis.13 The abscess must be drained and the child given antibiotics.14 The development of significant obstruction in tonsillar infections may require the use of corticosteroids, especially in the case of mononucleosis. The management of severe bacterial tonsillitis requires the use of antibiotics. Some children with recurrent tonsillitis benefit from adenotonsillectomy.15 2172 Aspiration of Foreign Bodies Aspiration of foreign bodies (FBs) into the airways usually occurs in children 1 to 4 years of age. More than 100 000 cases and 100 deaths occur each year.16 Most objects are expelled by the cough reflex, but some objects may lodge in the larynx, trachea, or bronchi. Large objects (e.g., hard candy, a bite of hotdog, nuts, popcorn, grapes, beans, toy pieces, fragments of popped balloons, or coins) may occlude the airway and become life-threatening. Items of particular concern would be batteries and magnets. The aspiration event commonly is not witnessed or is not recognized when it happens because the coughing, choking, or gagging symptoms may resolve quickly. FBs lodged in the larynx or upper trachea cause cough, stridor, hoarseness or inability to speak, respiratory distress, and agitation or panic; the presentation is often dramatic and frightening. If the child is acutely hypoxic and unable to move air, immediate action such as sweeping the oral airway or performing abdominal thrusts (formerly called the Heimlich manoeuvre) may be required to prevent tragedy. Otherwise, bronchoscopic removal should be performed urgently. If an aspirated FB is small enough, it will be transferred to a bronchus before becoming lodged. If the FB is lodged in the airway for a notable period of time, local irritation, granulation, obstruction, and infection will ensue. Thus children may present with cough or wheezing, atelectasis, pneumonia, lung abscess, or blood-streaked sputum. These children are treated by prompt bronchoscopic removal of the object and administration of antibiotics as necessary.17 Obstructive Sleep Apnea Syndrome Obstructive sleep apnea syndrome (OSAS) is defined by partial or intermittent complete upper airway obstruction during sleep with disruption of normal ventilation and sleep patterns. Childhood OSAS is common, with an estimated prevalence of 2 to 3% of children 12 to 14 years of age and up to 13% of children between 3 and 6 years of age.18,19 Prevalence is estimated to be two to four times higher in vulnerable populations (Blacks, Latin Americans, and preterm infants).18 In children, unlike adults, OSAS occurs equally among girls and boys. Possible influences early in life may include passive smoke inhalation, socioeconomic status, and 2173 snoring together with genetic modifiers that promote airway inflammation. Pathophysiology Reduced airway diameter and increased upper airway collapsibility are the common causes of OSAS. Obstruction of the upper airway during sleep results in cyclic episodes of increasing respiratory effort and changes in intrathoracic pressures with oxygen desaturation, hypercapnia, and arousal. The child goes back to sleep and the cycle repeats. Adenotonsillar hypertrophy, obesity, and craniofacial anomalies are associated with decreased airway diameter. Infants are at risk because they have both anatomical and physiological predispositions toward airway obstruction and gas exchange abnormalities.20 Reduced motor tone of the upper airways may be seen in neurological disorders, such as cerebral palsy and Down syndrome. Upper airway inflammation and altered neurological reflexes involving respiratory control of upper airway muscles are significant factors in reducing airway diameter. Allergy and asthma may contribute to inflammation, and children who have a history of a clinically significant episode of RSV bronchiolitis in infancy may exhibit altered neuroimmunomodulatory pathways toward inflammation in the upper airway.Obstructive Sleep Apnea Syndrome Presentation 21 In obese children, current research links OSAS with airway inflammation and elevated levels of C-reactive protein, which also contribute to increased risk for cardiovascular and metabolic disease.22,23 OSAS also may cause pulmonary disease, insulin resistance, and growth failure.24 Clinical manifestations Common manifestations of OSAS include snoring and laboured breathing, sweating, and restlessness during sleep, which may be continuous or intermittent. There may be episodes of increased respiratory effort but no audible airflow, often terminated by snorting, gasping, repositioning, or arousal. Daytime sleepiness/napping is occasionally reported, as well as nocturnal enuresis. There is no correlation between sleep position and OSAS in children, except for those children who are notably obese. Obese children may adopt the prone position to attempt improved ventilation. Cognitive and neurobehavioural impairment, excessive 2174 daytime sleepiness, impaired school performance, and poor quality of life are consequences of OSAS.25 Evaluation and treatment All parents should be asked if their child exhibits snoring, followed by a careful history and physical examination. A variety of screening tools are available. Imaging of the upper airway may be used to rule out adenoidal hypertrophy or upper airway narrowing.26 The most definitive evaluation is the polysomnographic sleep study, which documents obstructed breathing and physiological impairment. If obstructive sleep apnea is documented or strongly suspected clinically, children are most often referred for tonsillectomy and adenoidectomy (T & A) on the basis of described symptoms and physical findings, such as enlarged tonsils, adenoidal facies, and mouth breathing. For severely affected children who do not respond to T & A or who have different problems, such as obesity, continuous positive airway pressure (CPAP), anti-inflammatories, dental treatments, high-flow nasal cannula, and weight loss can be considered. Treatment is important to minimize associated morbidities.27,28 Quick Check 28-1 1. Compare and contrast pathology, clinical presentations, and severity of croup and epiglottitis. 2. What symptoms indicate aspiration of a foreign body? 3. What signs and symptoms suggest obstructive sleep apnea syndrome? Disorders of the Lower Airways Lower airway disease is one of the leading causes of morbidity in the first year of life and continues to be an important component of other illnesses progressing into childhood. Pulmonary disorders commonly observed include neonatal respiratory distress syndrome, bronchopulmonary dysplasia (BPD), infections, asthma, cystic fibrosis (CF), and acute respiratory distress syndrome 2175 (ARDS). Respiratory Distress Syndrome of the Newborn Respiratory distress syndrome (RDS) of the newborn (previously known as hyaline membrane disease [HMD]) is a significant cause of neonatal morbidity and mortality. It occurs almost exclusively in premature infants, and the incidence has increased in North America over the past two decades.29 RDS occurs in 50 to 60% of infants born at 29 weeks’ gestation and decreases significantly by 36 weeks. Risk factors are summarized in Risk Factors: Respiratory Distress Syndrome of the Newborn. Death rates have declined significantly since the introduction of antenatal steroid therapy and postnatal surfactant therapy. Risk Factors Respiratory Distress Syndrome of the Newborn • Premature birth or low birth weight • Male gender • Caesarean delivery without labour • Diabetic mother • Perinatal asphyxia Pathophysiology RDS is caused by surfactant deficiency, which decreases the alveolar surface area available for gas exchange. Surfactant is a lipoprotein with a detergentlike effect that separates the liquid molecules inside the alveoli, thereby decreasing alveolar surface tension. Without surfactant, alveoli collapse at the end of each exhalation. Surfactant normally is not secreted by the alveolar cells until approximately 30 weeks’ gestation. In addition to surfactant deficiency, premature infants are born with underdeveloped and small alveoli that are difficult to inflate and have thick walls and 2176 inadeq … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10