Download Pediatric Respiratory Rates

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Pediatric Process Paper
Sara Rothacher
Kent State University
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Data Collection
Description of Child and Family
AK was an 8 year old boy admitted to the Pediatric floor with a diagnosis of Asthma
exacerbation and pneumonia. AK was brought in on October 5th, 2011 weighing 33.2 kilograms,
55 inches in height and a date of birth of September 7th, 2003, making him almost exactly 8
years and 1 month old. He was brought in by his mother who works as a hair stylist at Famous
Hair Salon on Cleveland Avenue in Canton, Ohio. His father, who was not present at the time,
lives in East Canton and works as a cook in a downtown Canton restaurant. AK has only one
sibling, a twin brother, whom he is two and a half minutes older than. His brother was also not
present at the time due to it being a school day. AK lives with his mother and brother in Canton
Local but occasionally stays with his father for a night every couple of weeks. Neither, mom nor
dad was a part of any church or religious group at the time of admission. As for health
insurance, mom and the kids have Buckeye Community Health Insurance and dad at the time,
had none because he was recently between jobs. Dad does not abuse drugs or alcohol, and is a
current smoker who frequently smokes inside of the house. Mom stated that she does use
drugs or tobacco of any form but occasionally drinks alcohol, responsibly.
Developmental Assessment
AK’s expected developmental age, being 8 years old, would be that of a school aged
child. According to historically known Psychoanalytic, Sigmund Freud and Psychosocial theorist,
Erik Erikson, AK should be in the Latency stage (Freud), and the Industry versus Inferiority stage
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(Erikson) (Ball, Bindler & Cowen, 2010). In the Latency stage, Freud believed that the child
focuses on other activities related to social and cognitive growth and places importance on
privacy and understanding the body (Ball, Bindler & Cowen, 2010). AK exhibited this
developmental stage during his stay by constantly asking questions about the tubes, equipment
and treatments he was exposed to at the time and requesting to play video games any chance
he got. As for the Industry versus Inferiority stage, Erikson stated the child begins to gain a
sense of self-worth from involvement in activities (Ball, Bindler &Cowen, 2010). AK showed a
great interest in doing his breathing treatments and oral medication administration on his own
providing evidence of parallel between his chronological age and expected developmental age.
AK was showing appropriate fine motor skills for his age because he was usually busy playing
video games. My patient also demonstrated adequate gross motor skills by stating that he likes
to play basketball when he’s at his dad’s house and rides bikes and swims for fun in his free
time. AK’s language skills seemed well developed, although distracted at times by the video
games; he was able to answer any questions we asked him in an appropriate manner for his
age.
Nutritional Assessment
When assessing AK’s nutritional status, his mother stated that he eats a relatively well
balanced diet. His breakfast usually consists of cereal (Cheerios or Fruit Loops), yogurt, or
scrambled eggs and bacon with grape juice or 2% milk. His lunches and dinners vary depending
on where he’s eating at. What he eats at his mother’s house differs from what he eats at is
Dad’s or for school lunches. Mom stated that AK eats the regular school lunches consisting of a
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main dish; chicken patty sandwich, spaghetti, turkey gravy and mashed potatoes, etc., with two
sides such as corn, green beans, tater tots or fruit cocktail. AK chooses to drink either 1%
Strawberry milk or 2% white milk with his school lunch. AK stated that when not at school, his
favorite lunch foods are chicken nuggets, ham and cheese sandwiches or raviolis with 1% white
milk or fruit juice to drink. As for dinner, mom stated that she usually makes meals such as
pulled pork sandwiches, baked potatoes, spaghetti, macaroni and cheese or grilled cheese. As a
side dish, green beans, broccoli and cheese or baked beans with %1 white or chocolate milk to
drink. His mother stated that AK occasionally has a can pop to drink. AK’s mother said that his
snack patterns usually consist of wheat thins, gummy snacks, yogurt, potato chips or grapes.
When asked if AK has ever been put on any sort of diet or tried to gain or lose weight, his mom
said no. AK weighs 33.2 kilograms or 73 lbs, and is 55 inches (4 foot 7 inches).When calculating
AK’s BMI and percentage he fell under the 73rd percentile with a BMI of 17.0 putting him at a
relatively healthy weight for his age and height considering that anywhere from 5% to 85% is
considered healthy (Must & Anderson, 2007).
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AK
(Must A and Anderson SE. Effects of obesity on morbidity in children and adolescents. Nutrition in Clinical Care 2007;6(1):4–12.)
AK does not play any active sports at school but he did state that he likes to play basketball,
ride bikes, swim, play outdoors and use to take Karate with his friend at a local Karate class.
AK’s mother determined that he gets about 2 hours of daily exercise during the week and
anywhere from 5-7 on the weekends. The recommended daily caloric requirements for AK’s age
and gender are between 1,400-2,000 calories daily (Berg, 106).
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Pathophysiology
Pneumonia is a serious infection or inflammation of the lungs. It is characterized by the
lungs filling with fluid causing signs and symptoms of coughing up mucus yellow-greenish in
color, fever, chills, rapid breathing, chest pain, a fever exceeding 38.5 degrees centigrade (101.3
degrees Fahrenheit) and overall malaise (CDC, 2011). Pneumonia develops when foreign matter
such as viruses, bacteria, parasites, or fungus enters the lungs and causes inflammation.
Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the
single most common bacterial cause of pneumonia across all age groups (Chetty & Thompson,
p. 402). Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus
influenzae, Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella)
catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-negative bacilli
(Bellenir & Swanson, 201). Oxygen is life-saving in patients with pneumonia and is given when
oxygen saturations drop below 92%. The four most important criteria in assessing a child with
pneumonia are general appearance of the child (color and alertness), respiratory rate,
assessment of the breathing effort, and oxygenation (Chetty & Thompson, p.403). AK was
admitted with a temperature of 38.5 C (101.3 F), a harsh, productive cough and deep, labored
breathing with respirations around 45-50 a minute. The normal respiratory rate for an 8 year
old is described in the chart below.
Pediatric Respiratory Rates
Age
Rate (breaths per minute)
Infant (birth to 1 year)
30-60
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Toddler (1-3 years)
25-40
Preschooler (3-6 years)
20-30
School-age (6-12 years)
16-22
Adolescent (12-18 years)
12-18
Citation: Ball, Bindler & Cowen, 2010 (page. 1579)
Since AK’s respiratory rate was high, they also diagnosed him with Asthma exacerbation.
Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular
elements play a role: in particular, mastcells, eosinophils, T lymphocytes, macrophages,
neutrophils, and epithelial cells (Allen, 2009, p. 22). More specifically, asthma exacerbation is
defined as worsening asthma or an increase in the severity (Pauwels, 2007).In susceptible
individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest
tightness, and coughing, particularly at night or in the early morning. These episodes are usually
associated with widespread but variable airflow obstruction that is often reversible either
spontaneously or with treatment (Allen, 2009, p. 26). The inflammation also causes an
associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli.
Reversibility of airflow limitation may be incomplete in some patients with asthma (Hunt, 694).
Treatment
The usual course of treatment for a patient with pneumonia and asthma exacerbation is
symptomatic therapy (pain and fever control) including antibiotics if necessary and supportive
care through airway management, fluids, fever management, rest and education on asthma
flares, what to look for and avoid (Ball, Bindler & Cowen, 2010). The treatment used for AK was
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fever and asthma exacerbation control medications and antibiotics (listed below in Medication
chart), bed rest, keep the head of the bed elevated to promote adequate lung expansion, an
increase in fluids and oxygen and use of Acapella breathing treatments. An Acapella is an
airway clearance device used to help remove mucus from the airways by forcefully blowing into
the mouth piece of the device (Hoffman, 2011).
Medications
AK was ordered the following medications:
Name
Class/Action
Dose/ Safe dose for AK.
Side Effects
Use for A.K.
Albuterol
Bronchodilator; Beta
0.083%, 3mL = 2.5mg
Nervousness,
Treatment of acute
agonists (inhaled)
inhalation every 3-6
insomnia, cough
epidoses of
hours for children >4
and dry mouth.
bronchospasm or
- It stimulates beta(2)-
years old.
asthmatic episodes.
adrenergic receptors.
Binding of albuterol to
-Safe dose for AK
beta(2)-receptors in the
lungs results in
-AK was treated every 3
relaxation of bronchial
hours, inhalation.
smooth muscles.
Atrovent
Bronchodilator;
0.5mg=2.5mL
Headache,
Maintance therapy of
(ipratropium)
Anticholinergic (inhaled)
inhalation every 6
insomnia,
reversible airway
- inhibits vagally-
hours for children >4
nervousness,
obstruction to prevent
mediated reflexes by
years of age.
dizziness, dry
bronchospasm or
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antagonizing the action
-Safe dose for AK
mouth and
narrowing of the
of acetylcholine, the
-AK was treated every 6
nausea
airways.
transmitter agent
hours (inhalation)
released from the vagus
added after every other
nerve.
Albuterol treatment.
Headache,
Used to treat several
nausea, vomiting.
bacterial infections,
Azithromycin
Antimicrobial agent;
(zithromax)
Antibiotics; Macrolides
the first day
- Prevents bacteria from
5mg/kg PO every day
growing by interfering
on days 2-5, no longer
with their ability to
make proteins.
10mg/kg/day PO on
such as Pneumonia.
than 5 days.
-332mg/day safe on
Day 1, 166mg/day on
days 2-5 are safe doses
for AK.
-AK was treated with
160mg PO every 24
hours.
Rocephin
Antimicrobial agent;
50-75mg/kg
Pain, warmth or
Used to treat
(ceftriaxone)
Antibiotic;
intravenous divided
swelling at
infections caused by
Cephalosporins
every 12-24 hours.
injection site, and
bacteria such as,
- Interferes with
-1,660-2,490mg/12-
diarrhea.
Pneumonia.
bacterial cell-wall
24hours are safe doses
synthesis and division by
for AK.
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binding to cell wall,
-AK was treated with
causing cell to die.
1,600mg intravenouspiggy back(IVPB) every
24 hours with a rate of
100ml/hour.
Solu-Medrol
Steroids; Adrenal
0.5-2mg/kg/day
Headache,
Used to treat many
(methylpredn
cortical;
divided every 6-12
dizziness, nausea,
different conditions
isolone
Corticosteroids
hours
insomnia, dry
such as allergic and
sodium
-Prevents the release of
-16.6-66.4mg/day is a
skins and
breathing disorders
succinate)
the substance in the
safe dose for AK
increased
such as asthma.
body that causes
-AK was treated with
sweating.
inflammation.
15mg intravenous
every 6 hours =
60mg/day.
0.9% NaCl I
Isotonic solution
Maintenance dose:
Swelling or
Used as a source of
1000mL
containing 9g/L
10kg x 4= 40
edema may
water and electrolytes
Solution
Sodium Chloride
10kg x 2 = 20
occur.
to keep AK hydrated.
- Sterile, nonpryogenic
solution for fluid and
electrolyte
replenishment.
13.2kg x 1 = 13.2
Total = 73.2
73.2ml/hr is AK’s
maintenance rate that
was used.
Citation: Davis’s Drug Guide 2011
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Physical Assessment
AK’s focused assessment would include respiratory, due to the diagnosis, and vital signs
due to the side effects of the medications as well as the diagnosis. Respiratory assessments are
particularly important in AK’s situation not only because it is critical that we maintain an open
and clear airway for a patient with pneumonia/asthma, but it is important to analyze the
effectiveness of the medications given. The vital signs are just as important because we need
to be sure to maintain an adequate heart and respiratory rate, as well as to analyze the
effectiveness of the medications and to avoid an asthmatic episode. Temperature is also
extremely important to keep regulated to avoid dehydration and to be sure the pneumonia is
not worsening or that he has acquired any other illness while being immunosuppressed (Ball,
Bindler & Cowen, 2010). AK’s physical assessment at the time of admittance and through
hospitalization consisted of a harsh, productive cough, deep, labored breathing. His vital signs
revealed blood pressures ranging from 106-129 systolic/58-82 diastolic, heart rates anywhere
from 120-130 beats per minute, respiratory rates of 33-50 breaths per minute, temperatures
36.9-38.5 degrees Centigrade (98.4-101.3 degrees Fahrenheit), an O2 saturation of 88-94 on 1012L of oxygen at 55% through a Venti-mask and a reported 0 on a numeric pain scale of 1-10.
His lung sounds were diminished all over with crackles and wheezes in the left anterior and
posterior lobe.
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Lab Values and Diagnostic Tests
The following chart shows only the labs that were obtained from a complete blood
count and differential with neutrophils draw that had abnormal results. All other labs were
within normal limits.
Labs
AK’s Values
Normal Values
What it means
Potassium (K+)
3.3
3.5-5.5
AK was showing signs of
dehydration, possibly due
to his high fever.
Glucose
162
60-100
Uncontrolled blood sugar
levels often lead to
complications from
influenza and pneumonia
(Gill, 2011).
Lymphocytes
10.7
20-40
Sign of infection
(Ball,Bindler&Cowen,2010)
Monocytes
0.6
2.0-13.0
Sign of infection
(Ball,Bindler&Cowen,2010)
Neurtophil
87.1
50-75
Sign of infection
(Ball,Bindler&Cowen,2010)
Citation: Normal Values obtained from: Ball, Bindler & Cowen - page 1072-73
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The following chart describes the diagnostic tests and cultures taken.
Name
What it is/shows
Result
Nasopharyngeal Culture
This is a sample of secretions
Pending at the time of care
from the uppermost part of the
throat, behind the nose, to
detect organisms that can cause
disease.
Patient will be asked to cough
before the test begins and then
tilt their head back. A sterile
cotton-tipped swab is gently
passed through the nostril and
into the nasopharynx, the part of
the pharynx that covers the roof
of the mouth. The swab is
quickly rotated and then
removed.
Rapid Influenza A and B
Can help in the diagnosis and
Negative for both– This mean AK
management of patients who
did not have Influenza A or B.
present with signs and
symptoms compatible with
influenza.
A nasal aspirate is performed by
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using a syringe to push a small
amount of sterile saline into the
nose, then apply gentle suction
to collect the resulting fluid
(saline and mucus).
Beta Streptococcus culture
Used to determine if the patient
Negative – This means AK did
has Beta Strep.
not have Beta Strep.
A throat swab taken from the
tonsillar area and/or posterier
pharynx.
Computed Tomography Scan (CT
CT scans rapidly creates detailed
Cardiothymic silhouette was
Scan)
pictures of the body, including
within normal limits, a large area
the brain, chest, spine, and
of consolidation was seen in the
abdomen. The test was used to
left-lower lobe with obscuration
diagnose a possible infection in
of the left hemidiaphram. A
AK.
small left pleural effusion was
A computed tomography (CT)
suspected. Bilateral peripheral
scan is an imaging method that
infiltrates and peribronchial
uses x-rays to create cross-
thickening extending superiorly
sectional pictures of the body.
into the upper lobes and
inferiorly within the right-lower
lobe. – This mean AK was
positive for Pneumonia.
Citation: Centers for Disease Control and Prevention
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Normal Growth and Development
Normal growth and development might be affected by this condition for child AK’s age
by making the child more susceptible to other bacterial or viral infections during the infectious
process (CDC, 2011). Since AK’s immune system is suppressed due to his respiratory infection,
he is at a higher risk of acquiring other infectious pathogens at this time. Pat Bass M.D., of
Massachusetts General Hospital, did a study on the effects of pneumonia and asthma on
childhood development finding that children are also at risk for having wheezing and abnormal
pulmonary function tests in the future as well as being more likely to have abnormal pulmonary
function tests both 3 months and 3 years following an infection (Bass, 2011). His study also
stated that “ED treatment of acute asthma with unnecessary antibiotics is likely to contribute to
bacterial antibiotic resistance. Interventions are needed to reduce inappropriate antibiotic
prescriptions and to address disparities in asthma care” (Bass, 2011). Not only can asthma lead
to pneumonia, but the antibiotic use can also lead to a bacterial antibiotic resistance making it
more difficult to treat the pneumonia. AK’s growth and development may be affected due to
these same factors but also due to his use of inhaled corticosteroids and the affects it has on
growth and development. Inhaled corticosteroids can cause vertical growth to be stunted. The
height difference may be at most a few mere centimeters shorter than without the steroid but
still produces a significant stunt in growth (Ball,Bindler & Cowen, 2010). Another factor that
puts AK at risk for disturbed growth and development is the fact that his Dad smokes. Second
hand tobacco smoke increases the risk of developing pneumococcal diseases (Ball,Bindler &
Cowen, 2010). AK confirmed that his father does smoke tobacco inside the house frequently,
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putting AK at more of a risk of developing pneumococcal diseases and tiggering asthma
exacerbation again in the future.
Data Grouping/ Nursing Diagnoses
#1) Ineffective Airway Clearance r/t exudates in alveoli. (Ball, Bindler & Cowen, 2010)
A. Evident by his physical assessment including a harsh, productive cough, labored
breathing with lung sounds diminished all over with crackles and wheezes in the left anterior
and posterior lobe
(a) An increased amount of exudates can put a child at high risk for
aspiration, cyanosis and respiratory distress (Ball, Bindler & Cowen,
2010).
B. AK’s Respiratory rates anywhere from 33-50 bpm
(a) Bronchospasms, followed by onset of anxiety due to the fear of being
unable to gain a significant amount of oxygen will further increase a
child’s respirations with a risk of developing cyanosis (Ball, Bindler &
Cowen, 2010).
C. History of being exposed to second-hand smoke
(a) Exposure to tobacco smoke can increase the risk of pneumococcal
disease and can trigger asthma exacerbation (Ball, Bindler & Cowen,
2010).
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Goals:
Short Term: AK will mobilize pulmonary secretions within 24 hrs of admission.
Interventions:
1. Increase AK’s fluid intake to 2,000mL daily
a.) Rational- Adequate hydration is essential to thin and break up
trapped mucous plugs in the narrowed airways (Ball, Bindler &Cowen,
2010)
b.) Implementation- I frequently encouraged fluids and popsicles to AK
throughout my shift.
2. Encourage and teach AK how to effectively cough and deep breath PRN and use his
incentive spirometer q2hrs while awake.
a.) Rational - A weak, nonproductive cough causes secretions to be
retained in airways and interfere with gas exchange (Ball, Bindler &
Cowen, 2010).
b.) Implementation- I taught AK how to use an incentive spirometer and
a newly developed device called an Accapella which works the same way.
Long Term: AK will maintain a patent airway within the next 4-5 days of hospitalization.
Interventions:
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1. Administer all necessary respiratory treatments as ordered.
a.) Rational – Keeping the airway patent and free of secretions is critical
in pneumonia patients and achieved through proper respiratory
treatments. (Ball, Bindler & Cowen, 2010)
b.) Implementation – I witnessed Respiratory Therapy administer AK’s
Albuterol and Atrovent treatments q3hrs and every other treatment for
Atrovent.
2. Encourage and teach AK how to effectively cough and deep breath PRN and use his
incentive spirometer q2hrs while awake.
a.) Rational - Proper coughing and deep breathing opens alveoli and
prevents further atelectasis (Ball, Bindler &Cowen, 2010).
b.) Implementation – I taught and encouraged AK how to cough and
deep breath as well as how to use his Accapella treatment.
Evaluation:
Short Term: AK demonstrated proper cough and deep breathing techniques and clearer lung
sounds by the end of my shift.
Long Term: Was unable to obtain assessment due to end of shift.
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#2.) Risk for Deficient Fluid Volume r/t increased metabolic rate, fever and respiratory
distress (Ball, Bindler & Cowen, 2010).
A. Evident by his physical assessment including high fever of 101.3 degrees Fahrenheit
on admittance.
(a) When a child’s temperature remains high and their respiratory rate is
increased, the child is at risk for dehydration due to their larger body
surface area (Ball, Bindler & Cowen, 2010).
B. Increased respiratory rates of 33-50 bpm
(a) When a child’s temperature remains high and their respiratory rate
is increased, the child is at risk for dehydration due to their larger body
surface area (Ball, Bindler & Cowen, 2010).
C. Rapid heart rates ranging from 120-130 bpm
(a) If the heart beats too rapidly or too slowly for too long, the
heart eventually becomes unable to deliver a sufficient amount of
blood to the body (Ball, Bindler & Cowen, 2011).
Goals:
Short Term: AK will maintain a temperature between 36.4-37 degrees Centigrade (97.5-98.6
degrees Fahrenheit) within the first 24hrs.
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Interventions:
1. Monitor vital signs q4hrs and temperature every hour.
a.) Rational - The temperature will be decreased as a result of decreased
metabolism, or it may be increased if there is further infection. (Ball,
Bindler & Cowen, 2010)
b.) Implementation – I took vitals q4hrs and temperature every hour to
ensure AK was progressing in health.
2. Ascultate breath sounds right before and 20-30minutes after every respiratory treatment.
a.) Rational - Presence of wheezes may indicate bronchospasm or
retained secretions. (Ball, Bindler & Cowen, 2010).
b.) Implementation – I ascultated breath sounds before and 20 minutes
every treatment and was able to see AK’s progession.
Long Term: AK will maintain adequate fluid and electrolyte volume by discharge.
Interventions:
1. Weigh daily
a.) Rational - Rapid weight loss is a great indicator of dehydration in a
patient at risk for fluid deficiency (Ball, Bindler & Cowen, 2010).
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b.) Implementaion – I monitored AK’s input and output throughout my
shift as well as encouraged liquids often.
2. Teach family members signs and symptoms of dehydration before discharge.
a.) Rational - When a child’s temperature remains high and their
respiratory rate is increased, the child is at risk for dehydration due to
their larger body surface area (Ball, Bindler & Cowen, 2010).
b.) Implementation – I reviewed symptoms of dehydration with AK and
his mother and also taught them about the adequate type of fluids to
intake such as water and sports drinks and to avoid sodas.
Evaluation:
Short Term: AK demonstrated an adequate temperature range throughout my shift.
Long Term: Was unable to obtain assessment due to end of shift.
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References
-Allen, Julian Lewis. MD. & Stephens-Bryant, Tyra. MD. 2009. Guide to Asthma. What you need
to know. Hoboken, NJ: Parks & Crossing Co. (pages 22-43)
-Ball, Bindler & Cowen. 2010. Child Health Nursing. Partnering with Children and Families. 2 nd
Ed. Upper Saddle Ridge, NJ: Pearson Education Inc. (pages 190-1579)
-Bass, Pat. 2011. Can Asthma Cause Pneumonia? (September 27, 2011). Retrieved from
< http://asthma.about.com/od/adultasthma/a/Asthma-Pneumonia-Can-Asthma-CausePneumonia.htm>
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MA: Omnigraphics Inc. (pages 201-202.)
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Streptoccocus pneumoniae in Health Children. Retrived from
< http://wwwnc.cdc.gov/eid/article/8/5/01-0235_article.htm>
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http://www.cdc.gov/Features/Pneumonia.htm
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Children. Headington, Oxford; UK. Adis Data Information.
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< http://www.ehow.com/about_5127858_risks-high-blood-glucose-levels.html>
Hoffman, Gail. 2011. Henleys Med. Acapella. The Medical Center at the University of California,
San Fransisco. PDF.
<http://www.henleysmed.com/acapella/Acapella%20Protocol.pdf>
Hopfer, J, Vallerand, A, & Sanoski, V. (2010). Davis’s drug guide for nurses. Philadelphia: F A
Davis Co.
Hunt, F. John, Malik, Rajesh & Snyder, Ashley. 2010. American Journal of Respiratory and
Critical Care Medicine in Children. Volume 161. Number 3. (Pages 694-699).
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adolescents. Nutrition in Clinical Care. Washington: Morrison Publishing Inc.
Neumors Foundation. 2011. Kids Health. Pneumonia. Wilmington, DE.
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http://kidshealth.org/parent/infections/lung/pneumonia.html
-Pauwels, Romain. 2007. Proceedings of the American Thoracic Society. Similarities and
Differences in Asthma and Chronic Obstructive Pulmonary Disease Exacerbations.
Retrieved November 24, 2011. Ghent, Belgium; Department of Respiratory Diseases.
<http://pats.atsjournals.org/cgi/content/full/1/2/73>
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