Family Health Lecture March 18, 2015 University of Texas at Tyler Nurs 5329 Angela Preston, BSN, RN

Communicable Diseases “Children are the hands by which we take hold of heaven” -Henry Beecher Communicable Diseases Nurses play a key role in preventing infections in the pediatric population by confidently recognizing subtle signs and symptoms of infectious diseases in the community, initiating appropriate interventions, and providing education concerning availability and access of services. Any child who presents with a rash or fever needs a more thorough assessment Chapter 22

Lecture Objectives-taken from Syllabus COMMUNICABLE DISEASES   Expected Learning Outcomes: Identify common communicable diseases, collaborative management and prevention for pediatric population. Use the nursing process to describe the nursing care of a child with an infectious disease. Pre-class Assignments: Pediatric Chapter 22 pp. 497-518.

Immunizations for Children Measles, mumps, rubella- MMR Varicella- V Hepatitis A Influenza- FLU Meningococcal* Human Papilloma Virus- HPV* Hepatitis B Diphtheria*, tetanus*, pertussis-DTaP Polio- IPV* Haemophilus influenzae Type B –Hib* Pneumococcal- PCV* Rotavirus- RV* There is a schedule put out by CDC delineating at which age which vaccine needs to be given- important parents keeps up with well child appointments because it is here they would administer vaccines- if not up to date, will have to be given prior to entry to school (exemptions- Religious, Medical, Conscientious) Hep B – given to newborns, if mother HbsAg+ HBIG also given; 3 doses given before age 2 DTaP – 4 doses given for infants & toddlers (2, 4, 6mos, 15-18mos), final dose 4-6y; may cause irritability, loss of appetitie, localized swelling & tenderness to site; seizures rare side effect r/t pertussis component, much safer now since only acellular components used IPV – replaced live, OPV which could cause paralysis in immunodeficient children- not given in US since 2000; 4 doses @2, 4, 6-18mos, 4-6y; often in combo vaccine with DTaP Hib – bacterium that causes infection in various parts of body, @1 time was leading cause of meningitis in young children, 4 doses given @2, 4, 6, 15-18mos; not given after age 5 Pneumococcal – recommended for children<5y; protects from meningitis, otitis media, & other infections; high-risk condition: cochlear implants, sickle cell, congenital heart disease, asplenia Rotavirus – prevents severe diarrhea & dehydration, avoid if hx intussuseption or other GI disorder, oral MMR – live vaccine, don’t given before 1st b-day, 2nd dose 4-6y; may experience maculopapular rash, fever, swollen cheeks, mild joint pain; contraindication: allergy to neomycin or gelatin Varicella – don’t given before 1st b-day, 2nd dose 4-6y; side effects: erythema & soreness @site, rarely varicella-type rash @site; contraindication: allergy to neomycin or gelatin; don’t give if pregnant or immunocomprised Hep A – not given before 12mos, 2 doses given 6mos apart for high-risk or travel Influenza – annual, 6m-18y should receive annually, children under 8 receiving 1st immunization need 2 doses 4wks apart; >2y can rec live, attenuated influenza virus (LAIV) thru nasal spray (contraindicated w/asthma, immunodeficient) which may cause mild flu symptoms since manufactured from weakened form of live virus. CDC only recommends healthy* 2-8 yo children receive nasal spray; if nasal spray not available, just give flu shot. Flu virus may morph/change so that can alter effectiveness of vaccine. Meningococcal – 2 doses 8wks apart aged 2-10 if @high risk r/t asplenia, HIV+, or immunodeficiency, booster q5y; travel to countries where meningococcal is endemic need 1 dose; avoid if latex allergy or hx Guillian-Barre

General Considerations of Immunizations Private Insurance or State Funded Educate on possible side effects- including mild fever/cold symptoms or soreness/redness at injection site Teach appropriate doses of acetaminophen or ibuprofen for relief Provide Vaccine Information Statement (VIS) and obtain parental consent Document lot #, site, manufacturer Report all adverse effects of immunizations Location of administration Warm compresses @injection site Mild s/s of cold can still get immunizations, but hold if fever VIS sheet – purpose, side effects, care of child, contraindications & allergies; should sign consent form Report adverse effects – provider may file Vaccine Adverse Event Report (VAER) w/CDC Documentation – lot#, route & site, date Administer in anterolateral thigh NB-2yo, deltoid muscle 3-19yo

Types of Immunity Active immunity Passive immunity Natural active immunity Vaccine-induced immunity Passive immunity Natural passive immunity Passive immunity through immunoglobulins What is an example of each type?? Good review – see critical component: types of immunity p. 502 Active- permanent/long lasting immunity- person exposed to disease Natural- has infection- have a cold, get immunity to that specific virus Vaccine-exposed to weakened form of infection- Passive-temporary/lasts a few weeks or months Natural- passed from mother to fetus or nursing mother to breastfed baby i.e. cold viruses, etc IG- Immune globulins given to provide immediate protection against disease or infection i.e. exposure of infant to HBsAg + mother (mom is + for Hep B antigen) Hep B Immunoglobulin would be given

Types of Vaccines Inactivated or killed organism Live attenuated or weakened virus- can cause mild symptoms Acellular vaccine Toxoids Subunit of virus See critical component: types of vaccines p. 502 Inactivated- example- IPV- cannot replicate, but enough of original to stimulate immune response Weakened virus- example- MMR and Varicella Acellular- example- Pertussis, Hib- fragments of cells (does not contain whole cell) that stimulate immune response Toxoids- example- Tetanus, Diptheria- toxins produced by the bacteria are inactivated so cannot cause harm, but stimulate immune response Subunit-example- HepB- small fragments of viral protein are used Review clinical pearl: routes of vaccines p. 502 Nasal- flu for healthy* children 2-8yo if available Oral- RV SC- MMRV IM- DTAP, HepB, HepA, HPV, Flu, Hib, MCV, PCV, IPV

Critical Components of History Exposure to the disease Incubation period of the disease and the onset of symptoms Communicable diseases in the past Child’s immunization history Physical assessment, including prodromal and general signs and symptoms To assess child who may have communicable disease, hx essential Has child been around other children w/disease? Have family members been exposed to a communicable disease? Consider incubation period & length of time it takes for s/s to appear after exposure Has child had any communicable diseases in past? Is child up to date w/immunizations* Physical assessment – includes prodromal s/s (runny nose, cough, fever, malaise) that appear before rash or main illness appears, often assoc w/increased communicability; general s/s w/communicable disease: changes in behavior (lethargy, irritability); skin rashes that may itch, may be macules, papules, pustules, vesicles; enlarged lymph nodes, fever, n/v/d, pain See table 22-1: Summary of common communicable diseases p. 504-505

Universal and Standard Precautions Universal precautions: Prevent the transmission of bloodborne pathogens; provide guidelines for using protective barriers Standard precautions: more comprehensive, applying to patients in all settings Isolation guidelines: contact, droplet, and airborne precautions Promoting safety p. 503 Universal- gloves, gown, masks, eyewear Contact- gloves, gown – stool incontinence, rashes Droplet-gloves, gown, surgical mask, goggles (if expect resp fluid to spray) -flu, pertussis Airborne- gloves, gown, N-95, goggles(if expect resp fluid to spray) – special room with different venting- measles, chickenpox

Situations Requiring Emergency Services Difficulty breathing Blue, gray, or purple tinge to lips or skin Fever with headache or stiff neck Vomiting blood, or blood in stool Behavior changes: lethargy, acting withdrawn, unresponsiveness Seizure activity Purple or red rash Dehydration Critical component: caregiver education p. 503

15 Viral and Bacterial Communicable Diseases seen commonly in the Pediatric population Erythema Infectiosum (Fifth’s Disease) Hand-Foot-and-Mouth Disease Respiratory Syncytial Virus Bronchiolitis Roseola (Exanthum subitum) HHV 6 Hepatitis A Hepatitis B Influenza Mononucleosis Mumps (Parotitis) Rubella (German measles) Rubeola (Measles) Varicella zoster (Chickenpox) Bordetella pertussis (Whooping cough) Group A Strep throat/Scarlet fever Conjunctivitis (Pink eye)

Distribution of Content for the NCLEX-RN® Test Plan Blueprint Include: 1. Incidence in US & globally 2. If it is a vaccine-preventable disease; if so, what age vaccine is given along with information r/t vaccine 3. Physiological effect- how does virus or bacteria manifest itself in the body (include incubation period, prodromal phase and communicability) 4. Nursing management including: Assessment- expected signs and symptoms Comfort Treatment &/or medication- how disease is usually diagnosed, i.e. lab tests, is it viral or bacterial? Education 5. Special considerations/Higher risk population/Emergent care Distribution of Content for the NCLEX-RN® Test Plan Physiological Adaptation 14% Reduction of Risk Potential 12% Pharmacological and Parenteral Therapies 15% Safety and Infection Control 12% Health Promotion and Maintenance 9% Basic Care and Comfort 9% Psychosocial Integrity 9% Management of Care 20%

Resources www.ncsbn.org https://www.dshs.state.tx.us www.cdc.gov Textbook Powerpoint posted online for Mod 9 Communicable Diseases www.mayoclinic.org www.healthychildren.org

Team based Active Learning 1. Gather information and answer questions 2. Present information to class through skit, short powerpoint, Take notes on other groups

Viral Diseases— Erythema Infectiosum (Fifth Disease) Human parvovirus B19 Transmission by contact with respiratory secretions 4- to 21-day incubation period Contagious until rash appears “Slapped cheek” appearance Prodromal – fever, aches, HA Rash distribution – erythema of cheeks “slapped cheek” appearance; rash appears after cheek erythema characterized by lacy pattern on truck, may disappear & reappear if child becomes hot Systemic s/s – none after rash appears Diagnosis – blood test for presence of immunoglobulin M antibody indicates immunity Nursing interventions- can trigger crisis in those with sickle cell; can trigger aplastic crisis in immunodeficient children (should by placed on resp isolation, may not have typical rash but c/o fever, n/v, abd pain, malaise, lethargy) Home care – acetaminophen/ibuprofen for fever/pain, adequate hydration Can pass from pregnant woman to fetus*- if mother has had it in past, already has immunity, if unsure of exposure prior to pregnancy need to practice careful hand hygiene- possible complications: anemia, miscarriage (1st half of pregnancy) Once fever gone, can return to school.

Viral Diseases— (2) Hand-Foot-and-Mouth Diseases Agent: Coxsackie virus or enterovirus Transmitted by direct contact, respiratory, fecal-oral route 3- to 6-day incubation period May be shed for several weeks Small vesicles in mouth and on hands and feet s/s – cold symptoms, runny nose, fever, sore throat; sm vesicles appear in mouth & on palms of hand & soles of feet, may also appear on genitalia & buttocks Diagnosis – stool samples & throat swabs can be tested for presence of virus, but usually diagnosed clinically Caregiver education – careful hand hygiene & disposal of tissues; clean surfaces & toys w/soap & water & disinfect w/bleach solution (1tbsp bleach to 4cups water); bland food & drinks since mouth may be sore, ensure adequate hydration; acetaminophen/ibuprofen for fever/pain, OTC sprays & mouthwashes w/local anesthetic to relieve mouth pain Common in daycares

Viral Diseases — (3) Roseola (Exanthum Subitum), HHV-6 Respiratory Syncytial Virus Bronchiolitis Roseola (Exanthum Subitum), HHV-6 Agent: human herpes virus 6 Transmitted by saliva of persons who have the disease or are carrying the virus 9- to 10-day incubation period Communicability is unknown Pink or red papular rash appears on the day the fever returns to normal Agent: respiratory syncytial virus Transmitted by contact with saliva and nasal secretions; can live on surfaces for several hours; readily transmitted by hands 4- to 6-day incubation period Viral shedding may last 6 weeks Premature babies high risk of hospitalization if acquire RSV Clinical presentation for Respiratory Syncytial Virus Bronchiolitis- very common! s/s cold in older children: cough, congestion, fever As disease progresses in infants there may be resp distress w/tachypnea, wheezing, retractions, severe coughing, poor air exchange Diagnosis – RSV screening Nursing interventions Emergency care – virus may cause resp distress in infants & toddlers, emergency tx may be needed, prematurity or medical problems such as congenital heart defects esp vulnerable Acute hosp care – hospitalization needed for infants w/bronchiolitis & pneumonia in resp distress; contact isolation; freq assess resp status; sched activities to allow time for rest; cool humidified air; admin O2 as needed; hydration w/IVF if needed; bronchodilator nebs, inhaler tx Home care Careful hand hygiene & disposal of tissues Cool mist humifier, hydration Don’t administer OTC cough/cold products to children<4 Teach s/s resp distress in infant & when to seek medical care Immunizations to infants @risk (see Medication: Administration of Synagis p.510)- if Synagis given, must be given MONTHLY in premature babies- hospital will refer if baby needs it- expensive if self pay Texas DSHS designates RSV season by regions across state- generally end of October to end of March. Roseola (Exanthum Subitum), HHV-6 75% adults carry virus in saliva w/o symptoms, most people have had it by 4y Clinical presentation Prodromal – fever>103 x3-7d Rash distribution – papular pink or red rash that appears day fever returns to normal Diagnosis – typically based on rash, blood test may look for antibodies Nursing interventions – fever management at home Home care – fever mgmt: tepid bath, acetaminophen/ibuprofen

Viral Diseases — (4) Hepatitis A Hepatitis B Agent: hepatitis A virus Transmitted by contaminated food, fecal- oral route Incubation period approximately 30 days Most contagious for 2 weeks before onset of symptoms and for 1 week after onset of jaundice Agent: hepatitis B virus Transmitted by blood or blood products, sexual contact Incubation period on average is 90 days Can be spread as long as the virus is in the blood of an individual; some people are chronic carriers and carry the disease for life *What is given to newborns whose mothers are HbsAg+?* Hepatitis A Clinical presentation – fever, malaise, poor appetite, nausea, jaundice, abd pain, dark urine; <6y may be asymptomatic or mild symptoms, may play role in transmission Diagnosis – blood test for presence of anti-HAV IgM; other abn labs: presence of bilirubin in urine, elevated serum bilirubin, elevated liver enzymes (AST, ALT) Nursing interventions – Contact isolation if incontinent feces Immune globulin can be given after exposure to prevent or reduce severity Report incidence to health dept Home care Strict hand hygiene & sanitization of surfaces Appropriate rest & activity Nutritious, well-balanced diet In 2012, incidence was 0.5 cases per 100k (<5000) Hepatitis B Clinical presentation Aching, malaise, joint pain, jaundice, dark urine, loss of appetite, mild RUQ pain Children w/chronic may be asymptomatic & are @risk for developing hepatocellular carcinoma later in life Newborns may acquire perinatally, 40% infants who don’t rec post-exposure prophylaxis will develop chronic HBV – important to admin HBIG in addition to HBV if mom HbsAg+- admin in separate thighs, must admin HBIG within 12 hours of life High-risk groups among children & adolescents include those living in institutions, involved in IV drug use, infected by sexual partners, travel to Africa or Asia Hosp care – blood-borne precautions (see universal precautions) Don’t share toothbrushes or razors Importance of tx (see Medication: treatment for HBV p. 507) & f/u In 2012, 18760 new acute hep b cases (since vaccine created in 1991, 82% decr). 240 mil chronic hep b carriers globally- 786k deaths worldwide each year

Viral Diseases — (5) Influenza Mononucleosis Agent: influenza viruses Type A (H1N1), Type A (H3N2), or Type B Transmitted by contact with contaminated objects, coughing and sneezing 1- to 4-day incubation period Can be spread 1 day before until 7 days after symptoms Agent: Epstein-Barr virus Transmitted by person-to- person contact, sharing of personal objects 30- to 50-day incubation period Virus may be excreted for months following infection May develop splenomegaly or hepatomegaly Influenza Type A most prevalent Clinical presentation – fever, chills, HA, sneezing, cough, malaise, conjunctivitis, myalgia (aching) Diagnosis – rapid screening for flu virus antigens in nasal secretions Nursing interventions Emergency care – may trigger croup in infants Acute hosp care – pneumonia is complication that may require hospitalization, other complications: ear infections, sinus infections, dehydration, increased severity of medical conditions such as diabetes, asthma; isolation – droplet Home care Acetaminophen/ibuprofen for fever (no aspirin r/t risk of Reye syndrome) Careful hand washing & disposal of tissues Encourage increased fluid intake Admin of meds w/in 48h of s/s (see Medication: Treating Influenza p. 508) Importance of annual flu vaccine CAM tx – traditional Chinese medicinal herbs may be used to treat flu- share article – Chen et al 2008 Mononucleosis Clinical presentation Fever, sore throat, malaise, pharyngitis, enlarged posterior cervical lymph nodes w/symptoms lasting 1-4wks May develop splenomegaly or hepatomegaly Diseases primarily affect adolescents or young adults, children often have very mild symptoms Diagnosis - +mono spot test, +Paul-Bunnell heterophile antibody test, elevated lymphocytes, >10% atypical lymphocytes; EBV antibody titers Acute hosp care – hospitalization may be needed if child develops resp distress, abd pain w/splenomegaly, dehydration (Spleen can hold platelets) Prevent injury to spleen – no contact sports (football, basketball, soccer, rugby, baseball, boxing, hockey, rodeo, wrestling, martial arts, lacrosse, water polo) for 6-8wks Rest w/appropriate quiet activities & play Fever mgmt w/acetaminophen or ibuprofen Hydration & nutrition Counseling & emotional support for adolescents on BR

Scenario 12 month old infant in good health up to date on vaccinations presents to clinic with sudden onset of moderate fever (103 degrees) lasting for four days with otherwise non-specific complaints. Mother calls clinic because fever has returned to normal, but mild, pink, papules 1-5mm in diameter have appeared all over body. What is an appropriate nursing diagnosis? Use critical components of history: Up to date 4 days high fever Fever returned to normal then rash appeared Nonspecific complaints 75% of adults carry virus in saliva- most have disease by age 4 Roseola- fever management, fever has already gone away, rash usually lasts 2 days. Communicability is unknown. Would need to call doctor if: febrile seizure, fever hasn’t gone away after seven days, rash hasn’t gone away after 3 days Nursing care: fever mngmnt, bed rest, fluids Risk of impaired skin integrity Imbalanced body temperature

Viral Diseases — (6) Mumps or Parotitis Agent: paramyxovirus Transmitted by contact with oral and nasal secretions 16- to 18-day incubation period Can be spread 2 to 3 days before swelling of salivary glands up to 5 days after swelling starts Clinical presentation Swelling of salivary gland in front of ear, below ear, under jaw Boys may have painful swelling of testicles, girls may have ovarian involvement w/abd pain & breast inflammation Diagnosis – virus can be isolated from saliva Nursing interventions Emergency care – complications: meningitis, encephalitis, glomerulonephritis, permanent deafness, sterility, myocarditis, joint inflammation; infection during preg may result in fetal death; seek medical help for complications Acute hospital care – resp isolation Home care Acetaminophen/tylenol for fever/pain Bland, soft foods; bland liquids, avoid citrus juices, keep well hydrated Ice packs or warm compresses to neck for comfort

Viral Diseases — (7) Rubeola (Measles) Rubella (German Measles) Agent: measles virus Airborne through respiratory droplets or direct contact with secretions 8- to 12-day incubation period Can be spread 1 to 2 days before prodromal symptoms, 3 to 5 days before rash, and 4 days after rash appears Presence of Koplik spots in the mouth Agent: rubella virus Airborne through respiratory droplets or direct contact with secretions; also found in blood, urine, and stool 16- to 18-day incubation period Can be spread from 7 days before until 14 days after rash; starts at hairline and works down Rubella (German Measles) Most children contagious 3-4d before rash to 7d after rash Clinical presentation Prodromal – not present in children; adolescents may have mild fever, malaise, sore throat, HA Rash distribution – fine red or pink rash that appears on face 1st then spreads downward, lasts approx 3d & disappear in same order appear Systemic s/s – fever, aching, posterior cervical lymph nodes tender & swollen Home care Fever mgmt Importance of MMR vaccine before childbearing yrs- Rubella infection in pregnancy can cause congenital defects Rubeola (Measles) Prodromal – congestion, cough, conjuntivitis, fever, malaise, sm red spots in mouth w/bluish white center (Koplik spots) Rash distribution – brownish red macular rash starts @hairline & spreads downward over body Systemic s/s – fever, cough, red watery eyes, congestion Diagnosis – blood test to detect antibodies Nursing interventions Emergency care – complications: ear infections, diarrhea, encephalitis, pneumonia, seizures, deafness, mental retardation, death; seek medical care Acute hosp care – resp isolation Chronic hosp care – long-term care, including vent care, may be needed for child w/brain damage from measles encephalitis Keep child isolated for 5d after rash Dim lights if photophobia present, use warm compresses to remove crusting from eyes as needed Soft, bland foods; keep well hydrated w/plenty of fluids Cool mist humidifier

Viral Diseases — (8) Varicella- Zoster (Chicken Pox) Agent: Varicella zoster virus Transmitted by fluid from vesicles, secretions from nose, mouth and eyes, and airborne from coughing and sneezing 10- to 21-day incubation period Can be spread 1 day before rash appears until all vesicles have crusted over Same virus causes Shingles(Herpes Zoster virus) later in life Special considerations Possible to get 2nd time, usually more mild 15-20% vaccinated get virus, usually more mild Clinical presentation Prodromal – fever, malaise, congestion Rash distribution – 1st appears on trunk & face, spreads to other parts of body; goes thru stages of macule, papule, vesicle, & scab (crust) all present @same time, severe itching Systemic s/s – fever, HA, dehydration Diagnosis – visualizing rash Nursing interventions Emergency care – complications: bacterial infections of skin, pneumonia, septicemia, bleeding probs; urgent medical care needed Acute hosp care – may need hospitalization if immunocompromised or w/complications, IV acyclovir may be given; strict isolation – contact & resp Home care Avoid aspirin, use acetaminophen for fever, ibuprofen 6+mos Keep isolated until vesicles have crusted over Keep well hydrated Prevent itching – keep cool, dress in light cotton, distraction w/play activities, apply gloves or mittens if needed & keep fingernails clean & short Aveeno (oatmeal powder) or baking soda baths Calamine or cetaphil lotion to lesions Shingles- unvaccinated child cannot get shingles from someone with shingles or shingles from someone with chickenpox, but child may get chickenpox from adult with shingles if contact with lesion

What should the nurse say? A mother comes into the clinic concerned because her 6- year old daughter was just diagnosed with varicella zoster. The blisters have begun to scab over. There is a 3 year old and another 4 month old infant in the home. What does the nurse recommend regarding prevention of the disease? 3 year old should get the Varicella vaccine. If already caught will not prevent but may lessen symptoms. 4 month old infant is too young for varicella vaccine but educate on strict handwashing and not picking scabs, Keep 6 year old isolated- incubation period is 10 to 21 days but child is contagious 1 days before rash appears until all vesicles have completely crusted over. Keep 6 year old well hydrated to prevent complications and offer solutions to itching to improve healing time (oatmeal baths, calamine lotion, clear, short fingernails)

Bacterial Diseases — Pertussis (Whooping Cough) Agent: Bordetella pertussis Transmitted through oral and nasal secretions 6- to 21-day incubation period Contagious from the onset of symptoms and for about 2 weeks; infants not immunized may be contagious for at least 6 weeks DTaP- 2 month shots Cough ends with crowing (whooping), coughing “fits” Classic pertussis is characterized by 3 phases of illness: Catarrhal – lasts 1-2wks; cold symptoms including congestion, mild cough, fever Paroxysmal – lasts 1-6wks or longer; cough ends w/crowing (whooping) & may be severe enough to cause vomiting & cyanosis Recovery – cough gradually becomes less severe Some children & adolescents, may present as chronic cough that lasts for wks, whooping may or may not be present – immunity from childhood vaccine fades after 5-10yrs, most don’t know they have the disease and expose others; Tdap Booster vaccine became available in 2005 for adolescents Diagnosis – polymerase chain reaction (PCR) test identifies genetic material of bacteria of nasal secretions Nursing interventions Acute hosp care – infants may require hospitalization to manage resp distress & dehydration Complications that can occur during the course of pertussis include hypoxia, pneumonia, weight loss, seizures, encephalopathy, death Caregiver education Give sm amt fluid freq to keep hydrated, esp during bouts of vomitting Teach s/s resp distress & dehydration & urge to seek medical care as needed (see critical components: signs of respiratory distress & signs of dehydration p.516) Provide for rest & quiet activities & avoid stimuli that trigger coughing Cool mist humidifier Educate adults to get PERTUSSIS booster if coming into contact with newborns!!!!

Bacterial Diseases — (2) Strep Throat/Scarlet Fever Agent: Group A beta-hemolytic streptococcus Transmitted by respiratory droplets, direct contact with secretions 2- to 5-day incubation period Can be spread for 10 days without treatment; not contagious after 24 hours on antibiotics Scarlet fever is strep throat with a rash in “creases of body”, possibly strawberry-like tongue Swollen tonsils, may or may not have white pus pockets, may be associated with stomach ache Complications of GAS – rheumatic fever & poststreptococcal glomerulonephritis Clinical presentation Sore throat, fever, HA, enlarged & tender anterior cervical & tonsillar lymph nodes, abd pain, decreased appetite Cough & congestion aren’t major signs of strep throat, so if these are present likely caused by another organism <3y may have infection w/o complaining of sore throat, s/s include fever, irritability, nasal d/c Scarlet fever – strep throat w/fine red rash w/sandpaper texture; rash more pronounced in armpits & groin, creases of elbows, behind knees; after rash fades skin of fingers & toes may peel, may be pallor around mouth & white tongue w/swollen red papillae (strawberry tongue) Diagnosis – rapid strep test, throat culture Nursing interventions Emergency care – complications of untreated strep throat include glomerulonephritis & rheumatic fever Home care Administration of pcn as ordered Keep hydrated with extra fluids – soups, popsicles, milkshakes Cool mist humidifier Acetaminophen/ibuprofen for pain/fever Replace toothbrush Throat lozenges CAM tx – saltwater gargles

Conjunctivitis (Pinkeye) Agent: virus (adenovirus-cold) or bacteria Transmitted through contact with discharge from an infected eye, either directly or by touching contaminated surfaces Communicability varies depending on the organism Bacterial- classic pink eye, pink/red, swelling, purulent discharge, eyes “crusted” shut in AM, abx begin resolving in 24 hours Viral- pink, excessive tearing, may be slight crusting from tears, eyes might feel “dry”, no treatment available Both contagious- educate to change pillows nightly, not to share hand towels, meticulous hand washing, do not touch eyes, requires doctor appointment to diagnose and prescribe antibiotic eye drops (if bacterial), warm compress may help alleviate pain May cause re-infection if not cared for carefully, easily spread to both eyes and among family members, schools. Upon presentation to clinic, ask history Clinical presentation Viral – pink or red conjunctiva, edema, watery d/c; may be unilateral Bacteria – pink or red conjunctiva, edema, purulent d/c, crusted eyelids in am, c/o itching or pain Nursing interventions Teach administration of eyedrops as ordered for bacterial infections **clarify with parents saline drops won’t work If 2 or more children in same setting (home or school) develop conjunctivitis cause may be viral & lead to epidemic in school/group setting Home care – avoid touching eyes, careful handwashing after touching eyes, sanitize objects touched by eyes or hands, discard tissues used to wash eyes, admin eyedrops as ordered (see medication: administering eyedrops p. 514) - Student needs doctor note or resolution of symptoms to return to school

Question – 3 A mother is caring for her 9-month-old baby, who has respiratory syncytial virus, and is calling the pediatrician’s office for advice. She reports that the baby is fussy and doesn’t want to take her bottle. She just noticed she has only changed one wet diaper that day and when the baby cries she’s not seeing tears. Which of the following would be the appropriate recommendation by the nurse? “The baby will need to be seen by the doctor today. Let’s get you set up for an appointment .” “Suction the nose prior to feedings and provide them more frequently in small amounts. Offer pain relief as needed.” “The baby is in respiratory distress and needs to be taken to the emergency room immediately.” “Administer over-the-counter cough/cold medicine to help alleviate the symptoms.” Answer: B

Answer-3 The nurse knows the child is at risk for dehydration when the mother says she has had a notable decrease in wet diapers in 24 hours and is crying without tears. By suctioning prior to feedings, making them frequent and small, and comforting the infant through holding or giving pain relief if needed, the mother will be setting her child up for a successful feed. The nurse can recommend a visit to the pediatrician or ER if this does not increase diapers following this regime within a 12 hour period or if the child begins projectile vomiting or becomes lethargic.

Question – 4 A 4-year-old boy is brought into the pediatrician’s office for evaluation of fever, headache, and new-onset rash noted in his armpits and groin and behind his knees. The nurse assesses the boy’s mouth and throat and notices his tongue has a strawberry-like appearance. She inquires if the boy has been exposed to any sick children. The mother replies that several children in his daycare have had a sore throat. The nurse suspects which of the following communicable diseases? Exanthem subitum Hand-Foot-and-Mouth Scarlet fever Erythema infectiosum Answer: C

Answer – 4 Scarlet fever Scarlet fever is strep throat with a rash. A fine, red rash with the texture of sandpaper is more pronounced in the armpits and groin, in the creases of the elbows, and behind the knees. A strawberry tongue may also be noted. The child may also complain of stomach pain.

Minute Paper & Muddy Points: You may use bullets. 1. Starting now- write down in bullets what you learned today, starting with the most important and working down to less important points. 2. What was “muddy” or unclear that you want to know more about? Include your name because I will go review these and send out an email to clarify significant questions.