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Running Head: PEDIATRIC PROCESS PAPER 1 Pediatric Process Paper Sara Rothacher Kent State University Running Head: PEDIATRIC PROCESS PAPER 2 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 Running Head: PEDIATRIC PROCESS PAPER 3 (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 Running Head: PEDIATRIC PROCESS PAPER 4 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). Running Head: PEDIATRIC PROCESS PAPER 5 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). Running Head: PEDIATRIC PROCESS PAPER 6 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 Running Head: PEDIATRIC PROCESS PAPER 7 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 Running Head: PEDIATRIC PROCESS PAPER 8 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 Running Head: PEDIATRIC PROCESS PAPER 9 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. Running Head: PEDIATRIC PROCESS PAPER 10 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 Running Head: PEDIATRIC PROCESS PAPER 11 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. Running Head: PEDIATRIC PROCESS PAPER 12 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 Running Head: PEDIATRIC PROCESS PAPER 13 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 Running Head: PEDIATRIC PROCESS PAPER 14 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 Running Head: PEDIATRIC PROCESS PAPER 15 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, Running Head: PEDIATRIC PROCESS PAPER 16 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). Running Head: PEDIATRIC PROCESS PAPER 17 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: Running Head: PEDIATRIC PROCESS PAPER 18 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. Running Head: PEDIATRIC PROCESS PAPER 19 #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. Running Head: PEDIATRIC PROCESS PAPER 20 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). Running Head: PEDIATRIC PROCESS PAPER 21 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. Running Head: PEDIATRIC PROCESS PAPER 22 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> -Bellenir, Karen & Swanson, Jenifer. 2010. Infant and Toddler Health Sourcebook. 1 st Ed. Boston. MA: Omnigraphics Inc. (pages 201-202.) -Berg, M. Frances. MS, LN. 2007. Underage and overweight. America’s Childhood Obesity CrisisWhat Every Family Needs to Know. Long Island City, NY. (page 106) -Centers for Disease Control and Prevention. (November, 2011). Emerging Infectious Diseases. Retrieved from < wwwnc.cdc.gov/eid/pdfs/vol17no11_pdf-version.pdf> -Centers for Disease Control and Prevention. (September 29, 2011). Influenza- Rapid testing. Retrieved from < http://www.cdc.gov/flu/professionals/diagnosis/rapidlab.htm> -Centers for Disease Control and Prevention. (July 15, 2010). Nasopharyngeal Carriage of Running Head: PEDIATRIC PROCESS PAPER 23 Streptoccocus pneumoniae in Health Children. Retrived from < http://wwwnc.cdc.gov/eid/article/8/5/01-0235_article.htm> -Centers for Disease Control and Prevention. (November 7, 2011). Pneumonia. Retrieved from: http://www.cdc.gov/Features/Pneumonia.htm Chetty, Krishne & Thompson, Anne. 2007. Management of Community-Aquired Pnuemonia in Children. Headington, Oxford; UK. Adis Data Information. Gill, Pauline. 2011. What Are The Risks Associated With High Blood Glucose Levels? – eHow. < 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). -Must, Andrew & Anderson Sharen. 2007. Effects of obesity on morbidity in children and adolescents. Nutrition in Clinical Care. Washington: Morrison Publishing Inc. Neumors Foundation. 2011. Kids Health. Pneumonia. Wilmington, DE. Running Head: PEDIATRIC PROCESS PAPER 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> 24