1. Cracked lips
2. A normal appearance
3. Conjunctival hyperemia
4. Desquamation of the skin
Rationale: During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.
1. Restrict fluid intake.
2. Position for comfort.
3. Avoid strain on painful joints.
4. Apply nasal oxygen at 2 L per minute.
5. Provide a high-calorie, high-protein diet.
6. Administer meperidine (Demerol) 25 mg for pain.
Rationale: Sickle cell anemia is one of a group of diseases called hemoglobinopathies in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell, and insufficient oxygen causes the cells to assume a sickle shape; the cells become rigid and clumped together, thus obstructing capillary blood flow. Oral and intravenous fluids are important parts of treatment. Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, which is a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Therefore, the nurse would question the prescriptions for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, and a high-calorie, high-protein diet are important parts of the treatment plan.
1. Frequent handwashing is important.
2. The child should avoid exposure to other illnesses.
3. The child's immunization schedule will need revision.
4. Kissing the child on the mouth will never transmit the virus.
5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).
6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.
Rationale: AIDS is a disorder that is caused by the human immunodeficiency virus (HIV) and is characterized by a generalized dysfunction of the immune system. Both cellular and humoral immunity are compromised. The horizontal transmission of HIV occurs through intimate sexual contact or parenteral exposure to blood or body fluids that contain visible blood. Vertical (perinatal) transmission occurs when an HIV-infected pregnant woman passes the infection to her infant. Home care instructions include the following: frequent handwashing; monitoring for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity level, and oral lesions and notifying the health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications, as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; monitoring the weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids or changing diapers. Diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with their tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution made up of a 10:1 ratio of water to bleach.
1. DTaP (diphtheria, tetanus, acellular pertussis), MMR (measles, mumps, rubella), IPV (inactivated poliovirus vaccine)
2. MMR, Hib (Haemophilus influenzae type b), DTaP
3. DTaP, Hib, IPV, pneumococcal vaccine (PCV)
4. Varicella and hepatitis B vaccines
Rationale: DTaP, Hib, IPV, and PCV are administered at 4 months of age. DTaP is administered at 2 months, 4 months, 6 months, between 12 and 18 months, and between 4 and 6 years of age. Hib is administered at 2 months, 4 months, 6 months, and between 12 and 15 months of age. IPV is administered at 2 months, 4 months, 6 months, and between 4 and 6 years of age. The first dose of MMR is administered between 12 and 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of hepatitis B vaccine is administered between birth and 2 months, the second dose is administered between 1 and 4 months, and the third dose is administered between 6 and 18 months of age. Varicella zoster vaccine is administered between 12 and 18 months of age. PCV is administered at 2, 4, and 6 months of age and between 12 and 15 months of age.
1. Deep breath then exhale, rapidly whispering the word "huff"
2. Shallow breath then exhale, rapidly whispering the word "huff"
3. Deep breath, hold it for 15 seconds, then exhale slowly, whispering the word "huff"
4. Shallow breath, hold it for 10 seconds, then exhale rapidly, whispering the word "huff"
Rationale: The "huff" maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath, then exhaling rapidly, whispering the word "huff."
1. A red, swollen testicle
2. Nuchal rigidity
Rationale: The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. A red, swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication.
1. Awake, alert, interacting with the environment
2. The ability to think clearly and rapidly is majorly impaired.
3. The ability to recognize place or person is severely affected.
4. Sleeps unless aroused and, once aroused, interacts poorly with the environment
Rationale: Obtunded indicates that the child sleeps unless aroused and, once aroused, has limited interaction with the environment. Full consciousness indicates that the child is alert, awake, orientated, and interacts with the environment. Confusion indicates that the ability to think clearly and rapidly is lost, and disorientation indicates that the ability to recognize a place or person is lost.
1. Malaise, fatigue, and lethargy
2. Painful, stiff, and swollen joints
3. Limited range of motion of the joints
4. Stiffness that develops later in the day
5. Cool temperature of the skin over the affected joints
6. History of late afternoon temperature, with temperature spiking up to 105° F
Rationale: Clinical manifestations associated with JIA include intermittent joint pain that lasts longer than 6 weeks and painful, stiff, and swollen joints that are warm to the touch, with limited range of motion. The child will complain of morning stiffness and may protect the affected joint or refuse to walk. Systemic symptoms include malaise, fatigue and lethargy, anorexia, weight loss, and growth problems. A history of a late afternoon fever with temperature spiking up to 105° F will also be part of the clinical manifestations.
Rationale: If a child is severely thrombocytopenic, with a platelet count of less than 20,000/mm3, precautions need to be taken because of the increased risk of bleeding. The precautions include limiting activity that could result in head injury, using soft toothbrushes or Toothettes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories and rectal temperatures are avoided. The normal platelet count ranges from 150,000 to 400,000/mm3.