C h a p ter 4 3

Nursing Care of a Family

When a Child Has an
Infectious Disorder

KEY TERMS
• catarrhal stage • Koplik spots
• chain of infection • mode of transmission
• convalescent period • portal of entry
• enanthem • portal of exit
• exanthem • prodromal period
• exotoxin
• fomites
• reservoir
• septicemia  arty Ireland, a 10-year-old boy,
• incubation period • susceptible host was admitted to the hospital yesterday for
• interferon
appendicitis. This morning after surgery, his
throat is painful and his arms are covered by
a very itchy, red, macular (flat) rash. He was
diagnosed as having scarlet fever. His family
OBJECTIVES works as migrant farm workers. “His sister is
After mastering the contents of this chapter, you should be able to: home with mono,” his mother tells you. “How
1. Describe the causes and course of common infectious disorders of could our family get two infections plus
childhood.
appendicitis all in 1 week?”
2. Identify 2020 National Health Goals related to infectious disorders in
children that nurses could help the nation achieve. Previous chapters described the
3. Assess a child with an infectious disorder. growth and development of well children.
4. Formulate nursing diagnoses for a child with an infectious disorder.
5. Establish outcomes to help a family manage an infectious disorder This chapter adds information about
as well as manage seamless transitions across differing health care the dramatic changes, both physical
settings.
6. Using the nursing process, plan nursing care that includes the six and psychosocial, that can occur when
competencies of Quality & Safety Education for Nurses (QSEN): children contract an infectious disorder. It’s
Patient-Centered Care, Teamwork & Collaboration, Evidence-Based
Practice (EBP), Quality Improvement (QI), Safety, and Informatics. important to know about the spread and
7. Plan nursing care for a child with an infectious disorder, such as care of these diseases because many of
helping them understand infectious precautions.
them spread easily to other children.
8. Evaluate expected outcomes for the achievement and effectiveness of
care.
9. Integrate knowledge of infectious diseases with the interplay of How would you respond to Marty’s
nursing process, the six competencies of QSEN, and Family Nursing mother? Is it most likely that Marty
to achieve quality maternal and child health nursing care. contracted this new disease while he
was in the hospital, or before he was
admitted? What is a measure you would
recommend to help reduce the itching?

1252

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1253

BOX 43.1 Nursing Care Planning • Risk for infection related to presence of infective
organism in sibling or family member
Based on 2020 National Health Goals
• Altered body temperature (fever) related to systemic
infection
Several 2020 National Health Goals address ways to prevent • Fluid volume deficit related to insensible fluid loss
and reduce the incidence of infectious disease in children. from increased body temperature
• Knowledge deficit (learning) related to disease progno-
• Reduce, eliminate, or maintain elimination of vaccine-
sis, prevention, and treatment
preventable diseases such as measles from 115 infected
children per year to a target of 30 children per year. Additional diagnoses when children must be separated
• Achieve and maintain effective vaccination coverage from others to prevent infection transmission might
levels for universally recommended vaccines such as include:
the diphtheria, tetanus, and acellular pertussis (DTaP)
• Social isolation related to precautions required to pre-
vaccine among young children from 84% to 90%.
vent infection transmission
• Increase the number of states that use electronic data
• Deficient diversional activity related to activity restric-
from rabies surveillance to inform public health pre-
tion and precautions to prevent disease transmission
vention programs from 8 states to 29 states.
• Reduce central-line–associated bloodstream infections Outcome Identification and Planning
(developmental). When establishing outcomes for care of children with
• Reduce invasive health care–associated methicillin- infectious disorders, include those that help parents
resistant Staphylococcus aureus (HA-MRSA) infections deal with the current infection and also prevent another
from 26 per 100,000 people to 6.5 per 100,000 people infection such as teaching about necessary infection control
(U.S. Department of Health and Human Services [DHHS], precautions and immunizations. Parents often ask about
2010; see www.healthypeople.gov). communicability to their other children and to the infected
Nurses can help the nation achieve these goals by edu- child’s playmates or schoolmates, so these issues need to be
cating parents about the importance of immunizations addressed. Planning care for a child who requires restric-
and ways to avoid infections. They can also help prevent tions to prevent disease transmission requires a thought-
the spread of infection in hospital units by scrupulously ful consideration to prevent boredom. Two organizations
adhering to infection control precautions. helpful for referral are the National Foundation for Infec-
tious Diseases (www.nfid.org) and the Centers for Disease
Control and Prevention (www.cdc.gov).
Despite the number of preventive measures available, infectious Implementation
diseases remain a leading cause of morbidity in children (Beach Nursing responsibilities when caring for a child with
& Thalange, 2013). Nurses can play a key role in reducing the an infectious disorder depend on the setting in which
incidence of these disorders by educating parents about how the child is seen. Often, a child will not be brought
they are spread and appropriate preventive steps. It’s important into a clinic if the disease can be easily identified over
to be able to recognize their signs and symptoms because nurses the telephone. Counseling parents about techniques
are often the first health care provider to see evidence of infec- to relieve the irritation of rashes or other symptoms
tion as they triage children in emergency rooms or at school. can then be relayed to parents over the telephone or
Several 2020 National Health Goals, shown in Box 43.1, relate by e-mail as well. Administering antibiotics and being
to the prevention of infectious disorders in children. alert for potential adverse effects are other major nurs-
ing responsibilities.
Outcome Evaluation
Nu r s in g Pro c e s s Overview An evaluation of outcomes for a child with an infec-
tious disease should determine not only whether the
For a Child With an Infectious Disorder child is returning to wellness but also whether the
child and family have learned more about ways to pre-
Assessment
vent infectious diseases. If one member of the family
Many infectious diseases begin subtly. Parents report
has a decreased immune response due to steroid or
symptoms such as, “he doesn’t act like himself ” or “she’s
chemotherapy, prevention of transmission takes on even
so listless.” A day or so later, a rash develops. With many
greater importance.
disorders, children are infectious just before and just
Examples of expected outcomes that would indicate
after the rash appears. Rashes can be difficult to identify,
achievement of goals include:
so it is important to obtain as full a description and his-
tory of the rash as possible. • Child states pain from pruritus and skin lesions is at a
tolerable level.
Nursing Diagnosis • Siblings and family members remain free of signs and
Common nursing diagnoses used with children directly symptoms of the infectious disorder.
related to the infectious process include: • Parent names diversional activities she has planned to
• Pain related to pruritus from skin lesions keep the child occupied.
• Impaired skin integrity related to rash, pruritus, and • Parent verbalizes how to prevent transmission of infec-
scratching tious disease to other family members.

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 1254 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

THE INFECTIOUS PROCESS

BOX 43.2 Nursing Care Planning
Pathogens are any organism that causes disease and can be Using Assessment
classified into five types of microorganisms: viruses, bacte- Assessing a Child For Common Signs
ria, rickettsiae, helminths, and fungi. The properties of these and Symptoms of Infectious Disorders
organisms are discussed in conjunction with the common
diseases that they cause.
History
Stages of Infectious Disease Chief concern: Does child have a fever, general malaise,
vomiting, or diarrhea? Was child recently exposed to
Infectious diseases follow certain stages, during which the someone with an infection?
Past medical history: Are child's immunizations current?
communicability (i.e., ability to be spread to others) or sever-
ity of the illness can be predicted (Fig. 43.1). Physical examination
Linear abrasions
• The incubation period is the time between the invasion of Mouth: lesions on on scalp; sandlike
mucous membrane particles on hair
an organism and the onset of symptoms of infection. During (Koplik spots) shafts
this time, microorganisms grow and multiply. Although White plaques on (pediculosis)
incubation periods vary depending on the pathogen, a com- mucous membrane Nose: watery
mon interval is 7 to 10 days (although it can be longer). The (thrush) discharge
incubation period for tetanus, for example, is 2 to 21 days. Skin: warm and dry
(prodromal
• A prodromal period is the time between the beginning symptoms of
from fever;
measles)
of nonspecific symptoms such as lethargy, low-grade rash present
fever, fatigue, and malaise and the onset of disease-specific Swollen parotid
Reddened, gland (mumps)
symptoms such as a rash. Children are infectious (capable swollen pharynx
of spreading the microorganisms to others) during the pro- (infectious Pinpoint papules
dromal period, but because their symptoms are so vague mononucleosis, on an
pharyngitis) erythematous
at this point, they do not yet realize that they need to take Gray membrane base (herpes
precautions against spreading disease. During the prodro- in pharynx simplex)
mal period, therefore, infectious diseases spread readily (diphtheria)
Paroxysmal cough
through communities from a person with the disease to
(whooping cough)
any susceptible individual. Fortunately, prodromal stages Circular, scaly ring
(tinea corporis) Oozing, honey-
are generally short, ranging from hours to a few days. colored, crusty
• Illness is the stage during which specific symptoms either lesions of face and
related to the body organ affected or to the entire body Flesh-colored hands (impetigo)
papule
(systemic symptoms) occur, such as fever, increased white (plantar wart) Crusty lesions
blood cell count, or headache. Many childhood infections between fingers
have an accompanying specific rash on the skin (exanthem) (scabies)
or mucous membrane (enanthem) (Box 43.2).
• The convalescent period is the interval between when
symptoms first begin to fade and when the child returns to
a healthy baseline. Because fatigue is often an accompany-
ing symptom of infection, the convalescent period (or the Breaking the chain at one of its susceptible points is the
time until full energy is restored) may often take longer most efficient way to prevent infection from spreading
than anticipated. (Smith, 2011). Nurses are instrumental in doing this by
teaching parents activities such as good hand washing; they
Chain of Infection serve as first-line defenders against infections in health care
facilities.
The chain of infection is the method by which organ-
isms are spread and enter a new individual to cause disease.
Reservoir
Return to The reservoir is the container or place in which an organ-
Invasion of healthy ism grows and reproduces. The reservoir would be another
organism baseline person with the disease, a contaminated object such as
a kitchen counter, or an animal or insect. A major role of
immunizations is to help limit organisms’ use of children as
reservoirs for growth.
Clinical
Incubation Prodromal Convalescent
signs and
period period period
symptoms Portal of Exit
The portal of exit is the route by which an organism leaves
Period of communicability an infected child’s body to be spread to others. Organisms
FIGURE 43.1 The time frame for infectious diseases. Period can be carried out of the body by upper respiratory excre-
of communicability is the time during which the disease can be tions, feces, vomitus, saliva, urine, vaginal secretions, blood,
transmitted to other people. or lesion secretions (Table 43.1). To break a chain of infection

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1255

TABLE 43.1 Methods by Which Infections Spread

Portal of Exit Means of Transmission Portal of Entry Prevention Measures

Blood Arthropod vectors Injection into the bloodstream Decreasing exposure to vectors
Blood sampling Careful handling of blood sampling
equipment
Transfusion Prescreening of blood for organisms
such as HIV or hepatitis B

Respiratory secretions Airborne droplets Respiratory tract Wearing a mask

Fomites Droplet and airborne precautions
Hand washing

Feces Water, food Gastrointestinal tract Hand washing before eating, after using
Fomites bathroom, or after handling diapers
Vectors such as flies

Exudate from lesions Direct contact Skin, mucous membranes Contact precautions
Contact with soiled dressings Self-screening for sexual contacts
Gloves

at this point, follow a good aseptic technique and prescribed Means of Transmission
transmission-based precautions such as wearing a gown,
gloves, or mask and/or face shield as appropriate. Be certain The mode of transmission refers to whether the infection
to wash after contact with any body secretions as well as after is spread by direct or indirect contact. Sexually transmitted
coming into contact with any of the previous portal of exits. infections, for example, are spread by skin-to-skin or direct
Also be certain to supply an adequate number of disposable contact. Other infections are spread indirectly by fomites—
tissues to any child coughing or sneezing so droplet or air- inanimate objects such as soil, food, water, bedding, towels,
borne spread from these sources can be limited. Stress that combs, nonrefrigerated food, or drinking glasses. Insects,
hand washing is the most effective way to prevent the spread rats, or other vermin (vectors) also cause indirect spread.
of infection. The most common means of indirect contact, however,
is the spread of mouth and nose secretions (droplet infec-
tion) through talking, sneezing, coughing, breathing, kiss-
ing, and sharing drinking glasses or straws. Some droplets
containing pathogenic organisms are spread immediately
✔ QSEN Checkpoint Question 43.1 to another individual in this way. Some droplets fall to
Evidence-Based Practice the ground, where the organisms dry and then are spread
by dust. If small, the organisms become suspended in the
Because effective and frequent hand washing is so important air (airborne transmission) and can move with the wind
in preventing the spread of infection, researchers studied to infect people at a distance. A common respiratory tract
what factors most influence effective hand washing practices infection is an example of an illness spread by indirect
in children by investigating the practices of 2,323 sixth-grade contact.
students plus 2,089 of their parents. Results of the study To break a chain of infection at this point, use trans-
showed that health literacy, parents’ hand washing practices, mission-based precautions as appropriate and wash hands
parent and child bonding, and a greater amount of shared before, between, and after client care. Teach parents and
time together all had significant correlations with children’s children good hand washing techniques and other measures
hand hygiene practices (Song, Kim, & Park, 2012). as necessary.
Based on the previous study, what would be the most effec-
tive way to ensure Marty, the 10-year-old, consistently washes Portal of Entry
his hands before meals? The portal of entry refers to the opening through which a
a. Continue to remind him to wash his hands as often as possible. pathogen can enter a child’s body such as by inhalation, in-
b. Talk to Marty’s mother about the importance of modeling gestion, or breaks in the skin from bites, abrasions, or burns.
good hand hygiene practices. To break a chain of infection at this point, teach children
c. Explain to Marty the role that bacteria play in the to wash their hands after sneezing or coughing, before eat-
transmission of illness. ing, and after using the bathroom. Teach girls to wipe their
d. Stress that washing his hands makes him look grown-up perineum from front to back after defecating or voiding to
and responsible. prevent organisms from spreading from the rectum to the
Look in Appendix A for the best answer and rationale. urethra. Teach parents to wash cuts and abrasions before ban-
daging them.

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 1256 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

TABLE 43.2 Types and Functions of White Blood Cells (Leukocytes)

Type Percentage of Total Count Origin Function
Granular Forms

Neutrophils 60% at birth; 33% at 2 years of Bone marrow Active in acute bacterial infections
age; 60% thereafter

Eosinophils 1%–4% Bone marrow Increased in parasitic infection

Basophils 0.0%–0.5% Bone marrow Increased with inflammation

Nongranular Forms

Lymphocytes 30% at birth; Bone marrow T lymphocytes (stored in the thymus gland) directly react
50% at 2 years of age; with invading antigens; B lymphocytes from bone marrow
30% thereafter produce antibodies that inactivate antigens

Monocytes 5%–10% Bone marrow Serve as a backup for neutrophils in acute infection;
macrophages are mature form

Susceptible Host With activation of the immune system, B lymphocytes

(humoral immunity) and T lymphocytes (cell-mediated im-
For infection to occur, one more step must be present: the munity) begin to be produced. B lymphocytes form antibod-
child must be susceptible to the infection (susceptible host). ies specific to offending antigens that either actively destroy
Certain characteristics make some individuals more prone to them or activate complement, a special body protein that is
infection than others, including: capable of lysing (dissolving) cells (see Chapter 42).
• Age: Infection occurs most readily in the very young and T lymphocytes (thymus dependent) are often called killer
the very old. cells because they can destroy antigens by either direct con-
• Gender: Girls, for example, have more urinary tract tact or by the release of lymphokines. An example of a lym-
infections than boys. phokine is interferon, which is a substance that appears to
• Virulence: Some organisms are stronger than others or prevent cells from being host to more than one virus at a
cause disease more readily. time. This is why it is rare to see a child with two viral diseases
• Body defenses: Physical, chemical, and immune responses at the same time, although it is not impossible to see a child
all protect against foreign invaders. Children with immu- with both a viral and a bacterial disease (e.g., perhaps scarlet
nosuppression are more susceptible than others. Infants fever and a common cold) at the same time. This is also why
who are breastfed are less susceptible than formula-fed two virus vaccines are not given to a child at the same time
infants. unless they are specially designed to be given together (e.g.,
measles, mumps, and rubella). (See Chapter 42 for a more
The Body’s Immune Response to Organisms detailed discussion of the immune response and Chapter 34
for a discussion of immunizations.)
When a foreign organism (antigen) enters the body, it can be
destroyed by the phagocytic (cell-engulfing) action of white
blood cells, which seek it out or by activation of the body’s
immune system. Phagocytes are unique white blood cells HEALTH PROMOTION AND
(neutrophils) that are capable of cell destruction. Monocytes RISK MANAGEMENT
serve as backup cells for phagocytosis. The different actions of
all the white blood cells are summarized in Table 43.2. Preventing infectious diseases is important because these
The action of phagocytes on organisms produces pus disorders are responsible not only for a high percentage of
(remnants of the organisms, phagocytes, and destroyed tis- illnesses but also of hospital admissions in children. Preven-
sue). Children and parents alike may need a review of the tion begins with being certain all children are in general good
purpose of pus because they may think its presence indicates health. Adequate nutrition is important to provide protein
that an infection is becoming worse. More likely, it indicates and vitamins to supply adequate white blood cells so that
phagocytosis is occurring and the infection is resolving. both phagocytic and antibody-producing B lymphocytes are
If bacteria escape the action of the phagocytes, they enter available to destroy invading organisms.
the blood and lymph systems and are then transported A second important step is to be certain all parents are
to other body locations, activating the immune system. aware of the need for their children to be immunized. Nurses
Pathogenic organisms in the bloodstream create septicemia need to ensure immunizations are offered to children at
(blood infection), which is always a serious development be- health care visits so their immunizations can be kept up to
cause it means the organism is being spread systemically. date (Daley, O’Leary, & Nyquist, 2012).

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1257

It is important that parents also understand that although

diseases such as scarlet fever, chickenpox (varicella), and What if...43.1 You realize Marty, who was
mumps (infectious parotitis) are referred to as “common” diagnosed as having scarlet fever a day after
childhood illnesses, they have the potential to be extremely surgery for appendicitis, must have been infectious while
serious and can lead to complications such as pneumonia he was in surgery because that was his prodromal period.
and encephalitis. This is why, when children develop typical Will everyone, including yourself, who has been exposed
childhood communicable diseases, they need to be seen by to him need to be administered an antibiotic to keep from
a primary health care provider so the risk of these complica- contracting the infection?
tions can be minimized.
The responsibility expected of parents and children to
help prevent the spread of communicable diseases differs
from country to country and varies among cultures. In the CARING FOR THE CHILD WITH AN
United States, both federal and state governments have taken
an active role in preventing the spread of such diseases by INFECTIOUS DISEASE
requiring children to have immunizations against the most As almost all childhood infectious diseases include a fever or
common illnesses. Parents are expected to obtain such im- rash, nursing care must address identification and relief of
munizations for children by school age. Schools and school these symptoms.
nurses, as well as the school system’s frontline health officers,
take an active role in enforcing these regulations. Commu-
nity health nurses serve an important role in administering
immunizations and counseling families on how to prevent
the spread of disease in their homes. Nurses also have an
obligation to be certain parents are aware of the latest stud-
ies available on the safety of vaccines. Unfortunately, some
Nursing Diagnoses and
vaccines were associated with the development of autism Related Interventions
spectrum disorder in the past, causing some parents to be
reluctant to have their child immunized against any illnesses. Nursing Diagnosis: Pain related to pruritus from skin
Up-to-date evidence has shown there is no association be- lesions
tween autism spectrum disorder and vaccines, so the number Outcome Evaluation: Child states he is more comfort-
of children being vaccinated is again increasing (Lewis, able; reports less itching; is not seen scratching rash; no
Bernal, Shay, et al., 2010). signs of excessive scratching or bleeding are present.
Developing countries have a great deal of difficulty main-
taining this same level of disease prevention. Remember, Providing comfort for the pruritus of skin lesions is
when caring for children newly arrived from another country, important for many childhood infections. No matter
that the child may not have the same level of immunization as what agent is causing the disease, a rash tends to
usually seen. This opens an important area of health teaching, be extremely itchy and uncomfortable. Fortunately,
because the parents may not be aware of the importance of several simple remedies are available for reducing
immunizations, which ones are required, or what community discomfort (Box 43.4).
services are available to supply them. Some parents wrongly bundle up children who
have rashes, believing that the extra clothing pre-
Preventing the Spread of Infections vents a rash from turning inward and affecting the
heart. In reality, bundling only serves to make a rash
Nosocomial or health care–associated infections (HAI) are more uncomfortable and probably increases any
infections that are contracted while in a hospital or other accompanying fever. Although none of the previous
health care setting. They represent a major threat to hospi- measures are apt to be 100% effective, a second ad-
talized children because the overall rate of hospital-acquired vantage is that they give a parent a constructive and
infections in children range from 0% in low-risk settings comforting activity to carry out.
to 23% in high-risk settings such as intensive care units. Most infectious diseases also involve fever. Measures
Children younger than 2 years of age, children with a nutri- to combat fever in children are discussed in Chapter 37.
tional deficit, those who are immunosuppressed, those who
have indwelling vascular lines or catheters, are receiving Nursing Diagnosis: Social isolation related to re-
multiple antibiotic therapy, or who remain in the hospital quired activity restriction associated with precautions
for longer than 72 hours are at highest risk for contract- to prevent disease transmission
ing such an infection (Duval, 2010). Nurses provide a line Outcome Evaluation: Child states reasons for restric-
of defense against such infections by adhering to a strict tions; expresses interest in activities proposed by
aseptic technique, such as frequent and thorough hand nurses or parents.
washing, and by following protective transmission-based
precautions when indicated (Askarian, Yadollahi, Kuochak, A child who is restricted from others because of
et al., 2011). Summaries of standard infection precautions infection control precautions can begin to feel lonely
and transmission-based infection control precautions are and depressed unless stimulation and social needs
available at http://thePoint.lww.com/Pillitteri7e and in are met.
Box 43.3.

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 1258 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

BOX 43.3 Standard and Transmission-Based Precautions for Infection Control

To reduce the risk of disease transmission in the health care of the health care facility. Make sure the room has a door
setting: that can be closed.
1. Wash hands immediately with a non-antimicrobial soap 2. Wear a high-efficiency particulate air (HEPA) or other
and water before and after examining patients and after any biosafety mask when in the patient’s room.
contact with blood, body fluids, and contaminated items 3. Limit movement of the patient from the room to other areas.
whether or not you wear gloves. Place a surgical mask on a patient who must be moved.
2. Wear clean, nonsterile gloves anytime contact with blood,
body fluids, mucous membranes, or broken skin is likely. Droplet Precautions
Change gloves between tasks or procedures on the same Droplet precautions reduce the risk of pathogens being spread
patient. Before going to another patient, remove gloves, through large-particle droplet contact by acts such as coughing,
wash hands, and then put on new gloves. sneezing, and talking or through procedures such as suctioning
3. Wear a mask, protective eyewear, and gown during any patient or bronchoscopy. Large droplets do not remain suspended in
care activity when splashes or sprays of body fluids are likely. the air for long periods and generally travel only short distances,
Remove the soiled gown and wash hands as soon as possible. so close proximity is required for the spread of disease. If drop-
4. Make sure contaminated nondisposable equipment is let transmission is possible:
not reused with another patient until it has been cleaned, 1. Place the patient in a single-patient isolation room.
disinfected, and sterilized properly. Do not recap needles. 2. Wear a HEPA or other biosafety mask when caring for the
Dispose of nonreusable needles, syringes, and other sharp patient.
patient care instruments in puncture-resistant containers. 3. Limit movement of the patient from the room to other
5. Routinely clean and disinfect frequently touched surfaces in- areas. If the patient must be moved, place a surgical mask
cluding beds, bed rails, examination tables, and bedside tables. on the patient.
6. Do not touch linens soiled with blood or body fluids with
bare hands. Use plastic bags to transport soiled linen. Contact Precautions
7. Place a patient whose blood or body fluids are likely to con- Contact precautions reduce the risk of transmission of
taminate surfaces or other patients in an isolation room or area. pathogens by direct contact such as skin-to-skin contact
8. Minimize the use of invasive procedures to avoid the poten- (shaking hands) or indirect contact through an intermediate
tial for injury and accidental exposure. Use oral rather than object such as a comb or soiled dressing. If contact transmission
injectable medications whenever possible. is possible:
9. When a specific diagnosis is made, find out how the disease 1. Place the patient in an isolation room and limit access.
is transmitted. Use precautions according to the transmis- 2. Wear gloves during contact with the patient and with infec-
sion risk. tious body fluids or contaminated items.
3. Wear a disposable gown when in the patient’s room.
Airborne Precautions 4. Limit movement of the patient from the isolation room to
Airborne precautions reduce the risk of small-particle organisms other areas.
being transmitted through the air as microorganisms carried by this 5. Avoid sharing equipment between patients. Designate
route can be carried widely. If airborne transmission is possible: equipment for each patient if supplies allow. If sharing
1. Place the patient in a single-patient isolation room that is equipment is unavoidable, clean and disinfect it before use
not air-conditioned or where air is not circulated to the rest with the next patient.

From Siegel, J. D., Rhinehart, E., Jackson, M., et al., (2007). Guidelines for isolation precautions: Preventing
transmission of infectious agents in healthcare settings. Atlanta, GA: Centers for Disease Control and Prevention.

In a hospital setting, make as few trips as possible nursing responsibility. Remember that when children
in and out of the room to limit the possibility of patho- are admitted to a hospital, parents may not hear
gen spread; however, do not make care visits seem everything said to them during admission because of
hurried. If there is a procedure scheduled at 9:00 AM their anxiety. If the gowning technique was explained
and another at 9:30 AM, for example, stay in the room at the time of admission, therefore, do not assume
rather than leave to return again, if possible. Use the parents will remember the next day what was said.
time to read a story to the child, play a card game, or Explain and reinforce the technique as many times as
explore ways for the child to connect with friends and necessary to prevent them from exposing themselves
family through texting or via the Internet. to an infectious organism.
You may need to remind parents that they must Parents may be reluctant to give children who
follow these precautions, like all hospital personnel, require transmission-based precautions their favor-
when they visit. Some parents feel so self-conscious ite toy, thinking it will have to be destroyed after
about having to wash and gown that they may stay contagious precautions are discontinued. There are
away rather than visit. Helping them feel comfortable few toys, however, that cannot be scrubbed with
with these procedures so they continue to visit is a soap and water so there is no reason to restrict such

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1259

BOX 43.4 Nursing Care Planning Based on Family Teaching

RELIEVING THE ITCHINESS OF A RASH

Q. Marty’s mother says to you, “Our son is miserable because his rash is so itchy. What can we do to
help him?”
A. Itching is a very uncomfortable sensation. Use the following to help relieve the itch of a rash:
• Dress your child in light cotton clothing so overheating and perspiration do not occur. Perspiration can make itching worse.
• Avoid wool clothing, because it can irritate the skin and increase itching.
• Offer adequate fluid to maintain good hydration because dry skin increases discomfort.
• Keep your child’s fingernails short to avoid injury to the skin from scratching.
• Teach your child to press on an itchy area rather than scratching to relieve discomfort; cold cloths or compresses applied
to an area can also be helpful.
• Administer an analgesic, such as acetaminophen, as needed for comfort.
• Adding a few teaspoonfuls of baking soda to bath water can be soothing. Use lukewarm rather than hot water.
• Keep in mind that some children need an antihistamine such as diphenhydramine (Benadryl) to reduce itching. Ask your
primary care provider about using this medication.

items. Never leave children in a room before check- Exanthem Subitum (Roseola Infantum)
ing that they have a toy to play with or an activity
that will keep them busy for the length of time they • Causative agent: Human herpesvirus 6 (HHV-6)
will be alone. See Chapter 36 for a discussion of • Incubation period: Approximately 10 days
interventions that can be used to promote adequate • Period of communicability: During febrile period
stimulation for a child requiring transmission-based • Mode of transmission: Unknown
precautions as well as the role of a child life special- • Immunity: Contracting the disease offers lasting natural
ist to help locate and provide stimulating activities immunity; no artificial immunity is available
for children. Assessment. Roseola is a disease with severe symptoms, al-
though the illness itself is mild. It generally occurs in children
between 6 months to 3 years of age, and mainly in the spring
and fall, although it can occur at any time of the year. The first
symptom is a high fever (104° to 105°F [40.0° to 40.6°C]).
Infants become irritable and anorexic, although even with this
VIRAL INFECTIONS high a fever, usually remain playful and alert. Their pharynx
may appear slightly inflamed; the occipital, cervical, and post-
Viruses are the smallest infectious agents known, and are so auricular lymph nodes may be enlarged. If blood composition
small that they cannot be seen through an ordinary micro- is studied, the total white blood count is usually decreased,
scope. They actually are not true cells because they contain with the proportion of lymphocytes increased.
either RNA or DNA, but not both. Because they are incom- After 3 or 4 days, the fever falls abruptly and a distinctive
plete in this way, viruses cannot replicate on their own but rash of discrete, rose-pink macules approximately 2 to 3 mm
only by invading bacteria, plant, animal, or human cells and in size and flat with the skin surface appears (see Fig. 43.3).
using the biochemical products of those cells to function. The lesions occur most prominently on the trunk, fade on
Although body cells may not look to be outwardly altered by pressure, and last 1 to 2 days. The rash is darker than that
a viral invasion, they can fail to function or die because of of rubella or measles and, aside from the slightly reddened
lysis of internal components or rupture. Symptoms usually throat, children have no accompanying coryza (upper respi-
do not become apparent until many cells have been invaded ratory symptoms), conjunctivitis, or cough. The condition is
in this way, creating a long incubation period. Some viruses diagnosed based on the physical signs and symptoms with the
are capable of invading only specific cells. The Epstein–Barr hallmark appearance of a rash appearing immediately after
virus, for example, invades only B lymphocytes, HIV viruses the sharp decline in fever (Porth, 2011).
invade CD4 T lymphocytes, and influenza viruses affect spe-
cific receptor sites in tracheal cells. Other viruses are not so Therapeutic Management. Treatment focuses on measures to
selective. reduce the discomfort of the rash and fever such as acetamin-
ophen (Tylenol) or ibuprofen (Motrin). The most frequent
Viral Exanthems complication of roseola is a febrile seizure with the onset of
the disease because the temperature rises so rapidly. Manage-
The majority of childhood exanthems (rashes) are caused by ment of this type of seizure is discussed in Chapter 49.
viruses; each of these diseases has specific symptoms, charac- There are no long-term effects of roseola. If an infant
teristic lesions, and a specific distribution or pattern to the should develop this exanthem in the hospital, follow standard
rash that allows it to be identified (Figs. 43.2 and 43.3). infection precautions.

PILLITTERI_E7_CH43.indd 1259 7/8/13 6:36 AM

 1260 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

Macule Tumor Vesicle Papule

Plaque Bulla Nodule Wheal

Scale Crust Ulcer Fissure

Scar Erosion Atrophy

FIGURE 43.2 Primary and secondary skin lesions and their characteristics.

DAY OF DAY OF
ILLNESS 1 2 3 4 5 6 7 8 9 10 ILLNESS 1 2 3 4 5 6 7 8 9 10
TEMPERATURE

TEMPERATURE

104 104
103 103 Rubella
Measles
102 102
101 101
100 100
99 99
98 98
Rash Rash
Koplik Spots Malaise
Conjunctivitis Conjunctivitis
Coryza Coryza
Cough Lymph Nodes
DAY OF DAY OF
ILLNESS 1 2 3 4 5 6 7 8 9 10 ILLNESS 1 2 3 4 5 6 7 8 9 10
TEMPERATURE

TEMPERATURE

104 104 Exanthem

103 Scarlet 103
fever subitum
102 102
101 101
100 100
99 99
98 98
Rash Rash
Sore Throat Irritability
DAY OF
ILLNESS 1 2 3 4 5 6 7 8 9 10 11 12 13 14
104
TEMPERATURE

103 Chickenpox
102
101
100
99

Rash Scabs
Crops
FIGURE 43.3 The differences between five acute exanthems characterized by rash.

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1261

Rubella (German Measles) Measles (Rubeola)

• Causative agent: Rubella virus • Causative agent: Measles virus
• Incubation period: 14 to 21 days • Incubation period: 10 to 12 days
• Period of communicability: 7 days before to approximately • Period of communicability: Fifth day of incubation period
5 days after the rash appears through the first few days of rash
• Mode of transmission: Direct and indirect contact with • Mode of transmission: Direct or indirect contact with
droplets droplets
• Immunity: Contracting the disease offers lasting natural • Immunity: Contracting the disease offers lasting natural
immunity; a high rubella antibody titer reveals infection immunity
has occurred • Active artificial immunity: Attenuated live measles vaccine
• Active artificial immunity: Attenuated live virus vaccine (e.g., MMR)
(e.g., measles, mumps, and rubella vaccine) • Passive artificial immunity: Immune serum globulin
• Passive artificial immunity: Immune serum globulin is
considered for pregnant women Assessment. Measles is sometimes called brown or black,
regular, or 7-day measles to differentiate it from rubella
Assessment. Rubella (often called German or 3-day measles) (German, or 3-day, measles). Like rubella, because of high
is rarely seen today, but when it does occur, it is seen most vaccination rates, it is rarely seen today except for periodic
commonly during the spring and mostly affects older school- outbreaks that occur, usually in the winter or early spring,
age and adolescent children. The symptoms begin with a in underimmunized immigrant populations or underimmu-
1- to 5-day prodromal period, during which children have a nized college-age populations (Moss & Griffin, 2012). When
low-grade fever, headache, malaise, anorexia, mild conjuncti- it does occur, it can be a devastating illness because of the
vitis, possibly a sore throat, a mild cough, congestion, coryza, serious complications that can occur.
and swollen lymph nodes such as those in the suboccipital, The disease has a 10- to 11-day prodromal period dur-
postauricular, and cervical chains (Levin & Weinberg, 2012). ing which postauricular, cervical, and occipital lymph nodes
After the 1 to 5 days of prodromal signs, a discrete pink- become enlarged and the child develops a high fever (103°
red maculopapular rash (see Fig. 43.3) begins on the face, then to 104°F [39.5° to 40.0°C]) along with malaise. By the sec-
spreads downward to the trunk and extremities. On the third ond day of the prodromal period, coryza (rhinitis and a sore
day, the rash disappears. There is generally no desquamation throat), conjunctivitis with photophobia (sensitivity to light),
(peeling); if present, it is primarily fine flaking of the skin. and a cough develop. Koplik spots (small, irregular, bright-
Fever with rubella is not marked, although arthritis (joint pain) red spots with a blue-white center point) appear on the buc-
with effusion into the joints occurs in some children on the cal membrane. Unfortunately, the coryza of measles is indis-
second or third day and lasting as long as 5 to 10 days. tinguishable from that of a common cold (nasal congestion; a
mucopurulent discharge; and a deep brassy, bronchial cough)
Therapeutic Management. Children need comfort mea- when it begins. As a result, many children with measles are
sures for the rash and an antipyretic such as acetaminophen diagnosed as having a simple upper respiratory infection at
(Tylenol) or ibuprofen (Motrin) for fever or joint pain. If a this point and so, are encouraged to attend school, which eas-
child develops rubella while in the hospital, follow droplet ily spreads the disease.
precautions for 7 days after the onset of the rash in addition to Koplik spots are hallmark symptoms because they do not
standard infection precautions. appear with any other exanthem. They usually appear first on
If a woman contracts rubella while pregnant, it can cause ex- the buccal membrane opposite the molars and then extend to
tensive congenital malformation in the fetus (see Chapter 12). cover the entire buccal surface (Fig. 43.4). The raised base of
Because of this, it can never be considered a simple disease. the spots may coalesce so much that the blue-white centers
It is so important that girls are immunized against it before stand out like grains of salt on a wide erythematous base.
they reach childbearing age, that the vaccine is included in the By the fourth day of fever, a deep-red maculopapular rash
MMR vaccine. Because the vaccine contains a live virus, it is begins at the hairline of the forehead, behind the ears, and at
not recommended to obtain this immunization while pregnant the back of the neck and then spreads to the face, the neck,
(Centers for Disease Control and Prevention [CDC], 2012). upper extremities, trunk, and finally, the lower extremities

✔ QSEN Checkpoint Question 43.2

Safety
Suppose you are preparing to enter Marty’s room. Because
his infection involves potential airborne transmission, what
isolation precautions should you use?
a. Goggles and nonsterile gloves
b. Gown and nonsterile gloves
c. Mask, gown, and nonsterile gloves
d. No precautions provided Marty wears a mask
Look in Appendix A for the best answer and rationale. FIGURE 43.4 Koplik spots on the oral mucous membrane.
(© SPL/Custom Medical Stock Photograph.)

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 1262 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

child is hospitalized, follow airborne precautions for the

duration of the illness in addition to standard infection
precautions.

Chickenpox (Varicella)
• Causative agent: Varicella-zoster virus
• Incubation period: 10 to 21 days
• Period of communicability: 1 day before the rash to 5
to 6 days after its appearance when all the vesicles have
crusted
• Mode of transmission: Highly contagious; spread by direct
or indirect contact of saliva or open vesicles
• Immunity: Contracting the disease offers lasting natural
immunity to chickenpox; however, because the same virus
causes herpes zoster, the virus may be reactivated at a later
time as herpes zoster (shingles).
• Active artificial immunity: Attenuated live virus vaccine
• Passive artificial immunity: There is little passive placental
immunity to chickenpox. Children who are immunosup-
pressed, such as those with leukemia or HIV/AIDS, or
those who are being treated with corticosteroids are offered
varicella-zoster immune globulin (VZIG) within 72 hours
of exposure to help prevent or modify disease symptoms.
FIGURE 43.5 The typical rash of measles on a child’s upper Assessment. Chickenpox is another common childhood in-
body. (© NMSB/Custom Medical Stock Photograph.) fection that is decreasing in incidence because of required
immunization. The people most prone to it are those who
have not been immunized, such as immigrant children and
(Fig. 43.5). After several days, the rash typically turns from college students. The disease is marked by a low-grade fever,
red to brown. While the rash is red, it fades on pressure; when malaise, and, in 24 hours, the appearance of a distinctive rash
it is brown, it does not fade. This differentiates it from the (see Fig. 43.3). Varicella lesions first begin as a macula, then
rash of scarlet fever, which always fades on pressure. After 5 progress rapidly within 6 to 8 hours to a papule, and then
to 6 days, the rash fades, leaving a fine desquamation of skin a vesicle that becomes umbilicated and then forms a crust.
cells behind. It is important to note the skin of the hands and Each lesion is approximately 2 to 3 mm in diameter and is
feet does not desquamate, a feature again differentiating it surrounded by an erythematous area. When the first crop of
from scarlet fever. lesions appears, the child’s temperature usually rises markedly
Children with measles appear very ill because their cough to 104° or 105°F (40.0° or 40.6°C).
is loud and frequent, the coryza is acute, the fever is high, and Most of chickenpox lesions are found on the trunk, al-
the rash is pruritic. Fortunately, on the third or fourth day, though the face, scalp, palate, and neck also may be involved.
when their temperature begins to fall, the other symptoms They appear in approximately three separate series or crops,
clear quickly and children begin to feel better. Fever that lasts with each new lesion moving through progressive stages
beyond the third or fourth day of a rash or coughing that con- (Fig. 43.6). At some point, all four stages of lesions (macule,
tinues generally suggests one of the complications of measles, papule, vesicle, and crust) may be present.
such as pneumonia, has occurred.
Therapeutic Management. If the scabs from crusting are al-
Therapeutic Management. Children with measles need lowed to fall off naturally and lesions do not become sec-
comfort measures for the rash and an antipyretic for the ondarily infected, no scarring results. Scabs that are removed
fever. Nasal drainage does not respond to decongestants, prematurely, however, may leave a white, round, slightly in-
so the skin below a child’s nose may become excoriated dented scar at the site. For this reason, it is important that
from the constant nasal discharge. Applying a lubricat- children do not scratch and remove scabs. However, because
ing jelly or an emollient (e.g., A&D ointment) to the area the chickenpox rash is extremely pruritic, preventing scratch-
may help prevent excoriation. A cough suppressant to re- ing becomes a difficult problem for parents. A prescribed
duce coughing can be helpful; otherwise, the throat can antihistamine usually helps to reduce the itchiness to a bear-
become painful from frequent irritation. Because children able level, and an antipyretic will counteract the high fever.
with measles have photophobia, it can be painful for them Acyclovir, an antiviral, may be prescribed to reduce the num-
to look at bright lights, so it may be painful for them to ber of lesions and shorten the course of the illness (Karch,
watch television or use electronic devices. They are often 2013). The development of Reye syndrome (see Chapter 49)
more comfortable with the blinds or curtains drawn or has been associated with aspirin use during varicella and in-
when wearing dark glasses, so these measures should be in- fluenza virus illnesses, so caution parents to avoid aspirin and
stituted. Children need to be seen by a health care provider instead use acetaminophen or ibuprofen to control fever.
because the complications of measles include otitis media If the child is hospitalized, in addition to standard infec-
(middle ear infection), croup, pneumonia, airway obstruc- tion precautions, follow airborne and contact precautions
tion, and acute encephalitis (Moss & Griffin, 2012). If a until all lesions are crusted. Children may return to school

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1263

FIGURE 43.7 Herpes zoster on a child’s back.

(© Dr. P. Marazzi/SPL/Science Source/Photo Researchers.)

FIGURE 43.6 An older school-age boy with varicella.

(© Martin/Custom Medical Stock Photograph.)
Vaccination is no longer recommended; if exposed, vaccinia
immune globulin (VIG) might reduce the disease process.
as soon as all the lesions are crusted (i.e., the crusts are not The disease begins with a 3- to 4-day prodromal period of
infectious). Complications include secondary infections of chills, fever, headache, and vomiting. A rash and high fever
the lesions, pneumonia, and encephalitis. appear on about the third day. The lesions, most prominent
on the distal extremities and face, begin as macules, then
Herpes Zoster progress to papules, vesicles, and pustules, eventually crusting
Herpes zoster is caused by the varicella-zoster virus, the same over a 10- to 14-day period.
virus that causes chickenpox (Donohue, Kieke, Garguillo, Although the lesions of smallpox resemble those of chick-
et al., 2010). Apparently, the first time the virus invades, enpox, they can be differentiated by the appearance of the
children demonstrate the symptoms of chickenpox. With a pustular stage (not seen with chickenpox) and the fact that
second invasion, herpes zoster symptoms appear due to re- they arise as one crop of lesions, all progress at the same rate,
activation of a latent virus. Herpes zoster, therefore, tends to and the crusts are contagious.
occur in older children or young adults, although it can occur Smallpox is a serious illness; its mortality rate is as high
at any age. as 50% and it can be spread readily by direct or indirect
The first manifestations are pruritus and cutaneous ve- contact from one infected person to another. Disease symp-
sicular lesions on erythematous bases that follow the distri- toms can be modified by administration of VIG and an
butions of the lumbar and thoracic nerves (usually on the antibiotic to prevent secondary infection of lesions. Oxy-
trunk, face, or upper back) and cause deep, nagging pain gen or other measures to support respiratory and cardiac
(Fig. 43.7). function should be provided as necessary, or these systems
Treatment for herpes zoster includes analgesia for pain and can fail.
measures to reduce pruritus. Acyclovir, which inhibits viral
DNA synthesis, may be effective at limiting the disease. Ad-
ministration of VZIG may minimize symptoms. ✔ QSEN Checkpoint Question 43.3
Smallpox (Variola)
Patient-Centered Care

Smallpox is a disease that has been extinct in the world since Marty’s rash is causing him to scratch his skin. In order to
1995. Health care providers need to be able to recognize maintain skin integrity and promote comfort, which of the
symptoms of it, however, because viruses, colonies of which following actions should you prioritize in his plan of care?
are stored in various laboratories throughout the world, a. Ask Marty to rate his pain level on a pain scale.
could be used as an agent of biologic terrorism (Anderson & b. Administer an antihistamine as prescribed.
Bokor, 2012). c. Instruct Marty not to ever scratch the lesions.
The causative agent is the smallpox virus. The incuba- d. Cover his hands and fingernails with mittens.
tion period is 7 to 17 days, with a period of communicability Look in Appendix A for the best answer and rationale.
from the onset of the rash until all crusts have been shed.

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 1264 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

Erythema Infectiosum (“Fifth Disease”)

• Causative agent: Parvovirus B19
• Incubation period: 6 to 14 days
• Period of communicability: Uncertain
• Mode of transmission: Droplet
• Immunity: None
Assessment. Erythema infectiosum (the fifth important
childhood exanthem after measles, rubella, varicella, and
scarlet fever) occurs most often in children 2 to 12 years of
age. The first phase of the infection includes fever, headache,
and malaise. A week later, a rash, which erupts in three stages,
appears. In the first stage, a maculopapular rash that is in-
tensely red appears on the face, and is termed a “slapped face”
appearance (Fig. 43.8) (Smith, 2011).
A day after the facial lesions appear, the rash spreads to FIGURE 43.9 The “herald patch” of pityriasis rosea.
the extensor surfaces of the extremities; by the next day, it (© Dr. H. C. Robinson/SPL/Science Source/Photo Researchers.)
appears on the flexor surfaces and the trunk. These lesions
last for 1 week or more, although the facial rash may still
be present for up to 3 months. When lesions fade, they
fade from the center outward, giving the lesions a distinc- Pityriasis rosea tends to occur in school-age and older
tive lacelike appearance. After fading, lesions may reappear if children. Children may notice a short, mild prodromal
precipitated by skin irritation such as trauma, sunlight, heat, period of fever and sore throat. A herald patch, an erythem-
or cold. Some children develop joint pain and inflammation atous round lesion with a scaly border usually appearing on
as well. the trunk, is the first obvious lesion (Fig. 43.9). Approxi-
mately 1 week after the appearance of the herald patch, a
Therapeutic Management. Treatment is typically supportive, generalized rash of papules, vesicles, or urticaria appears,
with antipyretics and analgesics and comfort measures for the usually also confined to the trunk. The rash follows skin
rash (see Box 43.4). There are no known complications of lines, giving it the unique configuration of a Christmas tree
fifth disease for a child; it is teratogenic in a fetus, however, (Zawar & Chuh, 2012).
so children with this disorder should avoid contact with preg- The rash lasts 6 to 8 weeks. It is pruritic and, because it
nant women. Use droplet precautions in a hospital. Children lasts so long, is particularly worrisome to children and par-
can return to school as soon as the rash appears because they ents. Because the lesions, particularly the herald patch, are
are no longer infectious after this point. scaly at the edges, they are often confused with tinea corporis
(ringworm). Treatment is limited to oral antihistamines and
Pityriasis Rosea other comfort measures for rash.
• Causative agent: Unknown; associated with HHV-6 Pityriasis rosea appears to have no sequelae or complica-
• Incubation period: Unknown tions; in fact, it is difficult to demonstrate in what manner it
• Period of communicability: Unknown is infectious. It is a baffling rash of childhood, but children
• Mode of transmission: Unknown with it need to be seen by a health care provider so it can be
• Immunity: Apparently none differentiated from severe exanthems.

Enteroviruses
There are three main types of enteroviruses: echoviruses
(33 subdivisions), coxsackievirus A (24 subdivisions) and
coxsackievirus B (6 types), and polioviruses (3 subdivisions).
All three types cause illness in children.

Echovirus Infections
The echoviruses are responsible for a number of childhood
diseases, including aseptic meningitis, diarrhea, acute respira-
tory illness, and maculopapular rashes. Although potentially
serious, such infections are usually benign and self-limiting.
Treatment involves supportive measures such as an anti-
pyretic for fever and comfort measures for the rash. If a child
is hospitalized, follow contact precautions for the duration of
the illness in addition to standard infection precautions.

Coxsackievirus Infections
FIGURE 43.8 The “slapped face” appearance of fifth disease. The coxsackievirus groups are responsible, like the echo-
(© Dr. P. Marazzi/SPL/Science Source/Photo Researchers.) virus groups, for a variety of diseases. One of the most

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1265

frequently seen diseases caused by coxsackievirus A is her- Herpesvirus Infections

pangina. With this, children develop an abrupt elevation
of temperature, up to 104° or 105°F (40.0° or 40.6°C), Herpesviruses are responsible for both facial and genital lesions
which lasts 1 to 4 days. Anorexia, difficulty swallowing, in children.
sore throat, headache, abdominal pain, and vomiting may • Causative agent: Herpes simplex or herpes type 1 or type 2
also be present. Small lesions, generally discrete grayish virus
vesicles and pinpoint in size, appear on the tonsillar fau- • Incubation period: 2 to 12 days
ces, soft palate, and uvula (Lam, 2010). These gradually • Period of communicability: Greatest early in the course of
change to shallow ulcers surrounded by a red areola by the the infection
following day. After a few more days, they disappear and • Mode of transmission: Direct contact
the temperature returns to normal. There are generally no • Immunity: Immunity to a primary herpes response is
complications. gained after one incident. There is no immunity to recur-
Children need a soft or liquid diet while their mouth and rent herpes infections, however, because the virus lies dor-
throat are sore. If a child is hospitalized, follow contact pre- mant in the neurons of local ganglia until it is activated by
cautions for the duration of the illness in addition to standard stress, sun exposure, fever, other illness, or menstruation.
infection precautions.
Acute Herpetic Gingivostomatitis. Acute herpetic gingivosto-
Poliovirus Infections: Poliomyelitis matitis is the most common form of herpes simplex invasion
(Infantile Paralysis) in young children (Usatine & Tinitigan, 2010). An example
of the primary (not the recurrent) response, it occurs most
• Causative agent: Poliovirus often in children aged 1 to 4 years. Children develop a high
• Incubation period: 7 to 14 days fever (104° to 105°F [40.0° to 40.6°C]), are restless, and have
• Period of communicability: Greatest shortly before and anorexia with an edematous and erythematous pharynx. Their
after onset of symptoms, when virus is present in the gum line is also swollen, reddened, and bleeds easily. White
throat and feces (1 to 6 weeks) plaques or shallow ulcers with red areolae appear on the buc-
• Mode of transmission: Direct and indirect contact cal mucosa, tongue, and palate and perhaps on the tonsillar
• Immunity: Contracting the disease causes active immunity fauces. The anterior cervical lymph nodes are usually enlarged
against the one strain of virus causing the illness and tender. The disease runs its course in 5 to 14 days.
• Active artificial immunity: Inactivated polio virus (IPV) Children may need an antipyretic to reduce fever. They
vaccine also need soft, acid-free foods they can eat with minimal
• Passive artificial immunity: None irritation or abrasion. Popsicles and Jell-O are soothing
Polio is Greek for “gray,” the color of the spinal cord after it against inflamed mucous membranes. Oral acyclovir helps
atrophies from the effect of the poliomyelitis virus. No longer with healing. Use contact precautions with hospitalized chil-
seen in the United States thanks to effective vaccination pro- dren to avoid contact with lesions. Although usually mild, the
grams, poliomyelitis is still seen around the world, particu- disease can become serious, especially in infants, if the mouth
larly in India and parts of Africa, so immigrant children may becomes so sore that an infant cannot swallow, which then
be susceptible. The illness may be caused by any of the three leads to dehydration.
strains of poliovirus, which is why children are immunized
Herpes Simplex (Herpes Labialis). Herpes simplex infection,
with the trivalent (three-strain) vaccine.
popularly known as a cold sore or fever blister, represents the
Assessment. The poliovirus enters the child’s gastrointestinal recurrent form of a type 1 herpesvirus invasion that remains
tract, where it multiplies and produces symptoms such as dormant in the ganglia of the trigeminal or fifth cranial
fever, headache, nausea, vomiting, abdominal pain, and mild nerve. Herpes simplex typically appears as a cluster of pain-
stiffness of the neck, back, and legs. ful, grouped vesicles surrounded by an erythematous base on
As the virus invades the central nervous system, these the lips or skin surrounding the mouth. After 2 or 3 days,
initial symptoms change to intense pain and tremors of the vesicles crust and then gradually dry. Topical or oral acyclo-
extremities and then paralysis. Swallowing becomes difficult vir reduces pain and increases healing. Because children can
if laryngeal paralysis occurs; respiratory paralysis can halt res- feel conspicuous about the appearance of the lesion, they may
pirations (CDC, 2011a). need counseling to assure them the lesion is not as obvious to
others as it seems to them.
Therapeutic Management. Treatment for poliomyelitis is
bed rest with analgesia and moist hot packs to relieve pain. Acute Herpetic Vulvovaginitis (Genital Herpes). Genital her-
If the respiratory muscles are involved, long-term ventila- pes is caused by the human herpesvirus type 2, which remains
tion may be necessary. Survivors tend to develop progressive dormant in the ganglia of the sacral nerves. Because this
muscle atrophy (postpoliomyelitis muscular atrophy syn- form is spread primarily by sexual contact, it is discussed
drome) or severe arthritis in late adulthood, which further in Chapter 47 with other sexually transmitted infections.
reduces their ability to be self-sufficient (Gonzalez, Olsson, Normally, children rarely contract this form, so the occurrence
& Borg, 2010). in a young child suggests child sexual maltreatment (Reading,
Hughes, Hill, et al., 2011).
Viral Infections of the Integumentary System Warts (Verrucae)
Viral infections of the skin include herpes infections and Warts, one of the most common dermatologic diseases in
warts (verrucae). children, are caused by the papillomavirus. The virus has an

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 1266 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

incubation period of 1 to 6 months. The mode of transmis- Assessment. After the long incubation period of the virus,
sion is unknown, but it is probably by direct contact (Swanson children begin to show prodromal signs of malaise, fever,
& Canty, 2013). anorexia, nausea, sore throat, drowsiness, irritability, and
Warts appear as flesh-colored, dirty-appearing papules that restlessness. They may notice numbness or hyperesthesia
generally occur on the dorsal surface of the hands. Plantar at the area of the bite and along the course of the involved
warts appear on the soles of the feet and are painful when nerves. The white blood cell count begins to reveal a slight
children walk. These can be differentiated from calluses in that leukocytosis. If tested, the cerebrospinal fluid shows only a
they obliterate skin lines as they grow, whereas calluses do not. slight elevation in protein and cells. Symptoms such as high
Warts on the hands or the face generally are removed if fever, anxiety, and hyperexcitability increase; involuntary
they are cosmetically unattractive to children. Plantar warts twitching and generalized seizures may occur. When children
may have to be removed because of the discomfort they try to drink, they experience violent contractions of the mus-
cause. Parents can use over-the-counter wart-removing prepa- cles of the mouth leading to drooling of saliva. This phenom-
rations, such as Compound W (a salicylic acid solution), to ena gives the disease its former name: hydrophobia (“water
dissolve them. Application of a stronger prescription salicylic fear”) (Jackson, 2011).
acid solution may be prescribed to remove plantar warts. As symptoms progress, children will become comatose,
Carbon dioxide snow, liquid nitrogen, electrodessication, and with possible total body paralysis. Peripheral vascular collapse
cryotherapy are other methods also available for removal, but and death can follow as quickly as 5 or 6 days later. Postmor-
these methods are painful and rarely necessary. tem examination will reveal the diagnostic Negri bodies in
Children need reassurance that people do not catch warts brain cells.
from frogs or toads and that, even if left without any treatment, Therapeutic Management. Once the disease process begins,
warts will eventually fade by themselves after about 24 months. rabies is almost invariably fatal, so the key is prevention of the
Anogenital warts need special consideration because, like her- active process. All children who receive an animal bite should
pes type 2 lesions, they can be a mark of sexual maltreatment. be seen by a health care provider to evaluate the circumstances
They can be prevented by the human papillomavirus (HPV) surrounding the bite and to decide whether rabies prevention
vaccination, which is recommended for all children at 12 to measures should begin, a decision which must be made im-
14 years of age (Thornsberry & English, 2012). mediately if treatment is to be effective.
Take a history of the incident to determine the type of
Viruses Causing Central Nervous animal that caused the bite. Most children can be certain
System Diseases they know the type of animal if it was a dog or cat, but they
Viruses are the causative agent for central nervous sys- may be unsure if it was a wild animal. Be careful not to lead
tem disorders such as rabies, encephalitis, and meningitis. children into naming an animal just to please, such as, “Was
Encephalitis and meningitis are discussed in Chapter 49. it a skunk? A raccoon? A squirrel?” When names are sug-
gested in this way, children may choose an animal name as
Rabies if they are answering a multiple choice question, not because
they are certain of the type of animal. Instead, ask children
• Causative agent: Rabies virus to describe the animal; from that description, establish what
• Incubation period: 2 to 6 weeks, possibly as long as kind of animal must have bitten the child. It helps in rural
12 months health care facilities to have a picture book of animals handy
• Period of communicability: 3 to 5 days before the onset of so preschoolers, in particular, can identify the animal from a
symptoms through the course of the disease photo. Ask also how the animal acted because a rabid animal
• Mode of transmission: The bite of rabid animals; rarely usually runs blindly, often staggering; it may dribble saliva
through saliva from infected animals being transferred to rather than swallow it. It is easy for parents to assess whether
an open lesion on a child’s skin a household pet is acting unusual in this way. It can be more
• Immunity: Contracting the disease apparently offers active difficult to assess the actions of a wild animal because the fear
immunity, but few people have ever survived the illness to it experiences at being trapped or cornered may make it run
verify this about frantically.
• Active artificial immunity: Human diploid cell rabies vaccine An unprovoked attack is much more suggestive that the
• Passive artificial immunity: Rabies immune globulin (RIG) animal is rabid, rather than if the bite happened during a
Any warm-blooded animal can contract rabies. Although provoked attack. Let children know that they will not be
most people assume dogs are the most common source of punished if they were found to be provoking an animal so
infection, wild animals, such as skunks, squirrels, raccoons, they feel free to say so. Listen for statements such as “I was
and bats, constitute the primary sources of rabies infection only hugging him” or “I was just feeding him” because such
in the United States. Children are bitten more often by actions sound innocent, but may have constituted a provoked
dogs, however, and therefore, more children are treated for attack to the animal.
dog or cat bites. Rodents are seldom found to be rabid. Bites The kind of wound a child receives and the immunity sta-
from other children do not cause rabies, although therapy is tus of the animal are also instrumental in deciding whether
required because such bites usually contain streptococci. treatment will be necessary. A bite mark is much more seri-
When a child is bitten by an infected animal, the virus ous than a scratch from an animal’s claws, for example. If the
migrates from the bite area to the child’s central nervous system animal was properly immunized against rabies, it will rarely
over several days time, damaging cranial nerve and spinal cord transmit the virus. Whether rabies exists in the community
nuclei. Negri bodies (cytoplasmic inclusion bodies) can be iso- at the time of the attack is yet another factor that influences
lated from nerve cells to confirm the diagnosis (Jackson, 2011). the decision. If there have been no other reported instances

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1267

in domestic animals, the chance that this dog bite is serious • Apply mosquito repellant that contains DEET (use a
in terms of rabies is lower than if dogs with rabies have been concentration not over 30% and apply only once a day.
reported in the area. Don’t place it on children’s hands so they don’t ingest it or
Inspect the wound carefully to see whether it shows teeth use with infants younger than 2 months of age).
marks or scratch marks. Wash the wound well with an anti-
septic solution. If puncture wounds are present, the wound Other Viral Infections
must not be sutured and closed because tetanus (organisms
that are anaerobic and grow in deep, closed wounds where Mumps (Epidemic Parotitis)
oxygen does not reach) can develop in the wound in addition • Causative agent: Mumps virus
to rabies. The animal that caused the bite should be located, • Incubation period: 14 to 21 days
if possible, and confined for 5 to 10 days. If it develops any • Period of communicability: Shortly before and after onset
signs of rabies during this period, it will be destroyed and the of parotitis
brain will be examined for evidence of rabies. You can assure • Mode of transmission: Direct or indirect contact
people that domestic animals are not destroyed unless they • Immunity: Contracting the disease gives lasting natural
show signs of rabies or otherwise they may resist surrendering immunity
an animal for observation. • Active artificial immunity: Attenuated live mumps vaccine
If the animal is found to be rabid, children receive both (MMR)
the rabies vaccine and an antirabies serum (RIG). This applies • Passive artificial immunity: Mumps immune globulin
also if the animal escapes and its condition is unknown (i.e.,
it is assumed to be rabid). A portion of the RIG dose is Assessment. Mumps is now a rare disease in the United
injected into the wound site and the remainder is given intra- States due to successful immunization programs. If it does
muscularly. Antirabies vaccine is given immediately (day 0) occur, it is most likely to be in adolescents who have not
and then again on days 3, 7, and 14 (Karch, 2013). been immunized. If the disease occurs, it begins with fever,
It may seem contradictory to give an active immunization headache, anorexia, and malaise. Within 24 hours, pain on
serum (i.e., administering antigen to children) when they chewing and an “earache” occurs. When the child points to
have received an animal bite, which administers antigen to the site of the earache, however, the child does not point to
them. This is done, however, because the rabies virus has a the ear, but rather, the jawline just in front of the earlobe,
long incubation period before antibody production is stimu- which is the site of the parotid gland. By the next day, the
lated; administering RIG provides antibodies against the ra- gland appears swollen and feels tender, and the ear becomes
bies virus immediately. Administering the rabies vaccine al- displaced upward and backward. Boys may also develop tes-
lows the child to begin additional antibody formation so that ticular pain and swelling (orchitis).
by the time the rabies virus from the bite begins to have an It is often difficult to differentiate mumps from submaxil-
effect (2 to 6 weeks after the bite), the child has developed lary adenitis (swelling of lymph nodes). The best method of
sufficient antibodies to combat it and prevent the illness. differentiation is to place a hand along the child’s jawline. If
the major amount of swelling is above the hand, it is prob-
ably mumps. If the largest amount of swelling is below the
West Nile Virus Disease handline, it is probably adenitis (Fig. 43.10).
Although the West Nile virus may be transmitted by con- Therapeutic Management. Because chewing movements are
taminated blood products, it is usually spread by the bite of so painful, children may need soft, bland, or liquid foods
a mosquito after the mosquito has bitten and acquired the until the major portion of the swelling recedes (about 6 days).
infection from a natural host such as an infected bird, horse, They may need an analgesic for pain and an antipyretic for
squirrel, or reptile (Murray, Walker, & Gould, 2011). fever. Children are infectious prior to and for a few days after
Fortunately, most children who contract the disease remain parotid swelling appears and should be excluded from school
asymptomatic. A small number develop flulike symptoms until after this time. If a child is hospitalized, follow droplet
such as fever, fatigue, and malaise. The infection is serious, precautions in addition to standard infection precautions.
however, because some develop encephalitis, with symptoms Some parents worry that because their child had swell-
such as mental confusion, lethargy, photophobia, headache, ing only on one side, their child will develop mumps on the
muscle weakness, and coma, leading to death. West Nile virus opposite side in the future. One attack of mumps gives lasting
disease is diagnosed when antibodies to the virus are recov- immunity, however, so the child will not contract the disease
ered from blood serum. There is no evidence-based therapy again. If a child does appear to have contracted mumps twice,
for the disorder, except for supportive measures to maintain the diagnosis was probably confused with cervical adenitis ei-
function; however, ribavirin and intravenous immunoglobu- ther time.
lin (IVIG) have been used to reduce symptoms. There is also Mumps is a potentially serious illness because several
currently no vaccine for this condition. serious complications, such as meningoencephalitis or severe
Parents can help prevent the spread of West Nile virus permanent hearing impairment from neuritis of the auditory
disease by adhering to the “5D’s” (Murray et al., 2011): nerve, can develop. If mumps orchitis develops, only a single
• Instruct children to stay inside between Dusk and Dawn testis is usually involved, which swells rapidly and is painful
when mosquitoes are most prevalent. and tender. As soon as the fever declines, testicular swelling
• Drain standing water so there are few opportunities for also decreases, although the tenderness may exist for weeks.
mosquitoes to breed. Although atrophy of the testis may result, leading to a low
• Dress should include long pants and long sleeves when sperm count, the chance mumps orchitis will lead to com-
outside. plete subfertility is rare (Rundell, 2013).

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 1268 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

Parotid
gland

FIGURE 43.10 Epidemic parotitis. (A) The parotid gland is

located just in front of the ear. (B) A boy with parotitis (mumps).
(© Morris Huberland/Science Source/Photo Researchers.) B

✔ QSEN Checkpoint Question 43.4 The tonsils are enlarged, reddened, and often covered by a thick,
white membrane; petechiae appear on the palate (Fig. 43.11).
Teamwork & Collaboration If the mesenteric lymph nodes enlarge, children may experience
A nurse on your care team calls into work ill because she’s wor- abdominal pain so sharp that it simulates appendicitis. If the
ried she has contracted mumps (infectious parotitis). Which of spleen enlarges, it places the child at risk for spontaneous rup-
the following symptoms is most associated with mumps? ture. Other symptoms that may occur are hepatitis, a maculo-
papular eruption similar to the rash of rubella, pneumonitis,
a. A productive cough and a severe runny nose
and central nervous system involvement such as encephalitis,
b. Pronounced swelling behind both of her ears
meningitis, or polyneuritis.
c. Swelling above the jaw line in front of one ear
On a blood smear, lymphocytosis (lymphocytes represent-
d. Adenoid tonsils are reddened and swollen and hurt
ing more than 50% of the total white blood cell count) will
Look in Appendix A for the best answer and rationale. be present. A positive Monospot test, which can be reported
in minutes, or a heterophile antibody test, which must be
analyzed in a laboratory, along with the increased number of
Infectious Mononucleosis atypical lymphocytes apparent on a blood slide, confirms the
diagnosis. Antibodies against the Epstein–Barr virus can be
• Causative agent: Epstein–Barr virus assessed in blood serum for a final confirmation.
• Incubation period: Unknown; probably 2 to 8 weeks
• Period of communicability: Unknown; probably only
during acute illness
• Mode of transmission: Direct and indirect contact
• Immunity: One episode apparently gives lasting immunity.
No vaccination is available.
Infectious mononucleosis is also known as glandular fever
or, because it was first discovered as a disease that is trans-
ferred readily from one person to another by kissing, the
kissing disease. It occurs most commonly in adolescents and
young adults, although it may occur at any age of the child
(Katz, 2013). Complications that can occur include menin-
gitis or encephalitis.
Assessment. Following an incubation period of 4 to 8 weeks,
the beginning symptoms include chills, fever, headache,
anorexia, and malaise. Children develop enlarged lymph
nodes and a severe sore throat accompanied by a high fever FIGURE 43.11 The appearance of the tonsils in a child
(103°F [39.5°C]). with infectious mononucleosis. Note the degree of erythema,
The cervical lymph nodes are the ones most markedly enlargement, and purulent covering. (© Dr. P. Marazzi/SPL/
affected and feel firm and tender to touch; swallowing is painful. Science Source/Photo Researchers.)

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1269

Therapeutic Management. Children with infectious mono- When this happens, disease symptoms arise not from the
nucleosis need bed rest during the acute stage of the illness bacteria itself but from the effect of the toxins on the body.
(i.e., 2 to 3 weeks) because, with the splenomegaly, there is Tetanus, botulism, scarlet fever, and diphtheria are examples
a danger of spleen rupture with any trauma to that area. If a of diseases caused by the systemic spread of toxins produced
child is hospitalized, follow standard infection precautions. by bacteria.
Be careful in helping children with this disease turn in bed
so no pressure is placed over the splenic area. If palpating the Streptococcal Diseases
spleen, do so gently to avoid inadvertent rupture.
Teach children and parents the importance of maintaining Streptococci, which are gram-positive organisms, are found
a good fluid intake despite the sore throat; cool, nonacidic flu- normally in the respiratory, alimentary, and female genital
ids are often tolerated best. Caution children they may notice tracts and produce a myriad of types of infection. Most severe
weakness and general fatigue for up to 2 to 3 months after diseases in children result from infection with Streptococcus
the illness and to avoid contact sports as long as their spleen pyogenes (␤-hemolytic streptococci, group A). A ␤-hemolytic,
is enlarged. Because infectious mononucleosis occurs primar- group B streptococcal infection can be contracted from vagi-
ily in adolescents or young adults, it may interrupt school or nal secretions at birth (see Chapter 26) and so tends to occur
career plans. Help these young adults to voice their frustra- in newborns. Streptococcal pharyngeal infections are dis-
tion with this illness. Offer support to help them through this cussed in Chapter 40 with other throat infections. Rheumatic
unexpected interruption in their life (Porth, 2011). fever and glomerulonephritis, conditions that may result as
an autoimmune response to streptococci, are discussed in
Hantavirus Pulmonary Syndrome Infection Chapters 41 and 46, respectively.
The hantavirus is a member of the arbovirus group. The virus Scarlet Fever
infects small rodents and perhaps cats who have eaten mice.
Outbreaks occur sporadically, usually in families who have • Causative agent: ␤-hemolytic streptococci, group A
camped in an area with infected rodents. Symptoms such • Incubation period: 2 to 5 days
as fever, muscle aches, thrombocytopenia, gastrointestinal • Period of communicability: Greatest during acute phase of
upset, and hypotension occur 1 to 5 weeks after exposure. respiratory illness; 1 to 7 days
Death can occur from rapidly progressive pulmonary edema • Mode of transmission: Direct contact and large droplets
or kidney failure (Heyman, Thoma, Marié, et al., 2012). • Immunity: One episode of disease gives lasting immunity
Supportive care is necessary, as antiviral medications do not to scarlet fever toxin. No vaccination is available.
seem to be effective and there is no cure or vaccine available.
Caution families not to touch dead mice and to have mice Assessment. Scarlet fever occurs most commonly in the
exterminated from their homes to avoid the possibility of 6- to 12-year-old age group, although it may be seen in
contracting this disease. preschoolers. The incidence is highest in temperate climates,
and the disease occurs usually in late winter or early spring.
✔ QSEN Checkpoint Question 43.5 Symptoms begin abruptly and are those of streptococ-
cal pharyngitis: fever, sore throat, perhaps headache, chills,
Quality Improvement a rapid pulse, and malaise. As the ␤-hemolytic, group A
Marty’s sister is home with “mono,” or infectious mono- streptococcus grows in the child’s body, it produces several
nucleosis. In the event that she requires hospital care, toxins; erythrogenic toxin is the one responsible for a rash
assessment protocols should emphasize what action? that appears 12 to 48 hours after the onset of the pharyngeal
symptoms (see Fig. 43.3). The fever is high (103° to 104°F
a. Lymph nodes should be palpated before being percussed.
[39.5° to 40.0°C]) on the first day of throat symptoms and
b. The spleen should be palpated gently to prevent rupture.
again on the day the rash appears, but then gradually returns
c. Lymph nodes should be assessed by Doppler.
to normal.
d. Petechiae should be lightly massaged.
The rash is unique in that it is both enanthematous and
Look in Appendix A for the best answer and rationale. exanthematous (i.e., on both the mucous membrane and the
skin). The skin rash typically is red with pinpoint lesions that
blanch on pressure and feel as rough as sandpaper. They tend
to be densest on the trunk and very prominent in skin folds
BACTERIAL
BACTER
BACTE
BACTERI
BA
BACTE
AC
ACTER
CTE
CTER
TE
T ERI
ER
ER INFECTIONS (Pastia’s sign). The rash persists for approximately 1 week. It
desquamates, with large areas of skin peeling off in fine flakes
Bacteria are independent, living organisms with a nucleus (Patel, Lambert, Gagna, et al., 2011).
that contains both DNA and RNA. They reproduce by fis- In addition to the rash, the tonsils appear inflamed and
sion, in which one cell enlarges and duplicates itself, then enlarged and are usually covered with white exudate. The
divides into two equal parts. They occur in three main shapes: palate may be covered with reddened punctiform (pinpoint)
spheres (cocci), rods (bacilli), and spirals (spirochetes). lesions and perhaps scattered petechiae. The tongue, during
Types of bacteria can be distinguished after they are fixed the first 2 days of the illness, is white and appears furry. By
onto a laboratory slide and then stained. Bacteria that stain day 3, papillae enlarge and protrude through the white coat,
violet are said to be gram-positive organisms and those that giving the tongue a “white strawberry” appearance. By day
stain red are gram-negative organisms. Those that cannot 4 or 5, the white coat disappears and the prominent papillae
be decolorized with acid after being stained are acid-fast. of the tongue give it a “red strawberry” appearance. A “straw-
As some bacteria grow, they produce exotoxins, or poisons. berry tongue” is a hallmark symptom of scarlet fever and

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 1270 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

helps to differentiate the disease from other rashes or pharyn- lesions heal most quickly if a parent or the child also washes
geal infections. A throat culture, which reveals streptococci the crusts daily with soap and water.
along with the rash, is diagnostic. Although rare, complications of rheumatic fever or acute
glomerulonephritis may occur after impetigo, as with other
Therapeutic Management. Children with scarlet fever usually streptococcal infections. If a child develops impetigo while in
appear ill. They may need an analgesic and antipyretic, such as the hospital, follow contact precautions until 24 hours after
acetaminophen (Tylenol) or children’s ibuprofen (Motrin) for initiation of the antibiotic. If the infection does not heal or
pain and fever. They need a soft or liquid diet for a few days seems to be growing worse, parents need to notify their health
until their throat soreness has diminished enough that their care provider because impetigo can be caused by MRSA,
throat is not too sore to eat. Comfort measures are important which will need a systemic antibiotic for therapy rather than
for the rash. Because the underlying cause of the illness is a strep- a topical cream (Odell, 2010).
tococcal infection, a course of antibiotics is prescribed (Beach
& Thalange, 2013). Caution parents to give the full amount Cat-Scratch Disease
prescribed for the full course prescribed to prevent the compli-
cations of ␤-hemolytic, group A streptococcal infections (acute • Causative agent: Bartonella henselae bacteria
glomerulonephritis or rheumatic fever). If a child is hospital- • Incubation period: 3 to 10 days
ized, follow droplet precautions until 24 hours after therapy is • Period of communicability: Unknown
started, in addition to standard infection precautions, because • Mode of transmission: Bite or scratch from a cat or kitten
the child is infectious until this time (see Box 43.3). Box 43.5 • Immunity: One episode of disease gives lasting immunity;
shows an interprofessional care map illustrating both nursing no passive artificial immunity
and team planning for a hospitalized child with scarlet fever. Cat-scratch disease occurs most commonly in preschool
children because children at that age play roughly with cats or
✔ QSEN Checkpoint Question 43.6 pick them up and so receive scratches. At the time the child
Informatics contracts the disease, the cat does not appear ill.
The first symptom for the child is a single skin papule or
Marty, who has scarlet fever, is missing his school friends so is pustule that lasts 1 to 3 weeks. Approximately 1 to 2 weeks
eager to return to school. Because he received an antibiotic, after the scratch, a single lymph node of the head, neck, or
when should you inform the school nurse that it would be safe axilla becomes severely swollen. The swelling generally lasts
for him to return to school? several months.
a. Whenever he feels that he is strong enough Some children also have a low-grade fever and malaise.
b. Forty-eight hours after his spleen has returned to usual size Occasionally, central nervous system involvement, such as
c. As soon as his fever is within normal range encephalitis or meningitis, occurs. A positive reaction to a skin
d. Twenty-four hours after he began the antibiotic test of cat-scratch disease antigen will be present. This, along
Look in Appendix A for the best answer and rationale. with the history of a cat scratch and the aspiration of sterile
pus from the enlarged lymph node, is diagnostic. Treatment
is symptomatic, although an antibiotic may be prescribed to
Impetigo help shorten the course of the disease. Children may need an
analgesic to relieve pain from the swollen lymph node. Aspi-
• Causative agent: ␤-Hemolytic streptococcus, group ration of the involved node may be necessary to relieve pain
A (nonbullous); Staphylococcus aureus (bullous) or and make swallowing easier (Klotz, Ianas, & Elliott, 2011).
methicillin-resistant Staphylococcus aureus (MRSA) Parents may ask if the cat should be destroyed. Because
• Incubation period: 2 to 5 days an attack of cat-scratch disease gives lifetime immunity and
• Period of communicability: From outbreak of lesions until fewer than 10% of children scratched by the same cat con-
lesions are healed tract cat-scratch disease, there is no need to destroy the cat for
• Mode of transmission: Direct contact with lesions an act it may have seen as defending its safety.
• Immunity: None
Parents may be upset at being told their child has impetigo Staphylococcal Infections
because the lesions (which are dirty and crusty appearing) have
been associated in the past with poverty and poor hygiene. It Staphylococcal organisms are gram positive. Colonies of them
is common to see several children in a family with identical are normally found on the skin surface; therefore, they are
impetigo lesions because it is spread by direct contact. commonly the organisms involved in skin infections (pyo-
dermas). Because the organisms grow rapidly in cream foods
Assessment. Impetigo begins as a single papulovesicular lesion that are not well refrigerated, such as potato salad or cream
surrounded by localized erythema. Soon, more vesicles appear pies, they are also often the organisms involved in summer
and become purulent, ooze, and form honey-colored crusts food poisoning episodes. Because food poisoning produces
(Fig. 43.12). They are found most commonly on the face and gastrointestinal symptoms, these infections are discussed in
extremities. They are often seen as secondary infections of in- Chapter 45.
sect bites or in children who have body piercings. If there are
several lesions, children may have local swollen lymph nodes. Furunculosis (Boils)
Therapeutic Management. Treatment is oral administration A furuncle is a staphylococcal infection of a hair follicle.
of penicillin or erythromycin or the application of mupiro- A yellow pustule forms at the site. There is localized redness,
cin (Bactroban) ointment for 7 to 10 days (Box 43.6). The pain, and edema of the surrounding skin. Moist heat for

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1271

BOX 43.5 Nursing Care Planning

AN INTERPROFESSIONAL CARE MAP FOR A HOSPITALIZED CHILD

WITH SCARLET FEVER
Marty, a 10-year-old boy, was admitted to the hospital having scarlet fever. “His sister is home with mono,”
yesterday for appendicitis. This morning after surgery, his mother tells you. “How could our family get two
his throat is painful and his arms are covered by a infections plus appendicitis all in 1 week?”
very itchy, red, macular rash. He was diagnosed as

Family Assessment Child has three siblings: a 16-year-old white and furry. Throat culture positive for streptococcus.
sister and two brothers, 6 years and 10 days old. Parents Other physical examination findings within normal limits
are migrant crop workers. Family moves yearly from Flor- for postoperative course. Child upset and crying, saying,
ida to Connecticut to follow crops. Mother rates finances “I wish my Mom was here to stay with me. I can’t even go
as: “We have no money.” to the playroom.” Mother usually visits once a day in the
late afternoon.
Client Assessment Macular, pinpoint erythematous
rash on abdomen, groin folds, and chest. Lesions blanch Nursing Diagnosis Social isolation related to required
with pressure. Groin and elbow areas hyperpigmented. restrictions associated with infection-control precautions
Child scratching constantly. Uvula and pharynx beefy
red. Tonsils inflamed and enlarged with white exudate. Outcome Evaluation Child states reason for restrictions,
Temperature: 103°F (39.5°C). Pinpoint lesions with two identifies time when restrictions will be lifted, and
or three scattered petechiae noted on palate. Tongue expresses interest in activities proposed.

Team Member
Responsible Assessment Intervention Rationale Expected Outcome
Activities of Daily Living, Including Safety

Nurse Assess what child Review the reason for Child may associate Child states he under-
understands about restrictions and infec- precautions and stands reason for
how communicable tion control precau- restrictions with isolation. Cooperates
diseases are spread. tions. Institute droplet feelings of being to maintain infection
precautions. punished. Droplet precautions.
precautions help
reduce the spread
of the disease.
Nurse Assess what play Visit the child frequently, Frequent visits help to Child states that although
activity would provide and provide him with decrease feelings he wants to go to play-
stimulation. opportunities for of being alone. room, he has found an
therapeutic play. Therapeutic play helps enjoyable activity to
the child deal with occupy his time in his
resentment about hospital room.
condition.

Teamwork & Collaboration

Nurse/Primary Determine whether hos- Consult with infection Scarlet fever is contagious Infection control officer
health care pital infection control control members on for 1 to 7 days prior to states she is aware of
provider committee is aware of the possibility that the outbreak of a rash. possible spread of ill-
contagious illness in a surgical personnel may ness and the need for
postoperative patient. have been exposed to penicillin for exposed
scarlet fever. health care personnel.

Procedures/Medications for Quality Improvement

Nurse Determine whether child Begin antibiotic therapy Penicillin is effective for Child’s parents are con-
has ever had a reac- as prescribed. group A ␤-hemolytic tacted and report child
tion to penicillin. streptococcus, the has not had a previous
causative organism of reaction to penicillin.
scarlet fever. Child takes oral peni-
cillin as prescribed.
(continued on page 1272)

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 1272 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

BOX 43.5 Nursing Care Planning (continued)

Nurse Ask child to rate pain Administer analgesia and An antihistamine such as Child states the itchiness
of sore throat and antihistamine prescribed. Benadryl can greatly of rash and pain
itchiness of rash on Caution child that anti- reduce the pruritus of of sore throat have
scale of 1 to 10. histamine may make him a rash. decreased to tolerable
feel sleepy. levels.

Nutrition

Nurse/ Assess what fluid child Provide frequent oral Adequate fluid intake is Child identifies favorite
Nutritionist would find most fluids. When soft diet is important to prevent fluid to drink. States
appealing to drink. begun (child is post-op skin dryness, which he is able to eat
appendicitis), provide increases discomfort. soft foods even with
soft foods. A soft or liquid diet painful throat.
is less irritating to the
child’s sore throat.

Patient-Centered Care

Nurse/ Determine whether other Explain the purpose of Because family members Parent identifies susceptible
Primary care members of family will prophylactic penicillin were near the child dur- family members; states
provider need a prophylactic for susceptible family ing the prodromal pe- she will be able to fill
antibiotic. members. riod, they are suscep- prescription and super-
tible to also contracting vise to be sure they take
the disease. prescribed antibiotic.

Psychosocial/Spiritual/Emotional Needs

Nurse Assess whether child and Discuss that the spread of Mother voiced she was Mother and child state
parent understand the infectious diseases is not concerned because they understand
cause of scarlet fever. related to “good or bad” two diseases hap- diseases are caused by
values. pened to her child infectious organisms,
at the same time. not moral status.

Informatics for Seamless Health Care Planning

Nurse Assess if parent is aware Discuss possible measures the If children scratch pruritic Parent states she
the child’s rash will be parent can take to reduce lesions, they can cause understands common
itchy for about 1 week. pruritus (e.g., loose cloth- a secondary infection. measures to reduce
ing, cool compresses) and Sore throats interfere pruritus and will
measures to reduce pain of with comfort and an begin them.
sore throat (e.g., analgesic). ability to eat well.

20 minutes applied to the lesion can help relieve pain. Urge

children not to rupture these lesions but rather to allow them
to run their self-limiting course so the infection is not spread
to surrounding tissue and does not become a cellulitis.
Cellulitis
Cellulitis is staphylococcal inflammation of the deeper layers
of skin. It occurs generally on the extremities or face, or sur-
rounding wounds. The skin feels warm to the touch and is
edematous and reddened. Warm soaks help relieve pain and
inflammation. Therapy is a systemic antibiotic.
Methicillin-Resistant Staphylococcus aureus
MRSA is a strain of staphylococcus that causes skin infections
and has become resistant to common broad-spectrum antibi-
otics. When an infection occurs in a health care setting, it is
referred to as health care–associated MRSA or HA-MRSA.
If it occurs in a community setting, it is termed community-
FIGURE 43.12 Impetigo in a toddler. Note the honey-colored associated methicillin-resistant Staphylococcus aureus (CA-
crust appearance of some of the lesions. (© Dr. P. Marazzi/SPL/ MRSA). Children with weakened immune systems are at the
Science Source/Photo Researchers.) greatest risk for contracting the infection.

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1273

BOX 43.6
6.7 Nursing
NursingCare
CarePlanning
PlanningBased
BasedOn
onResponsibility
ResponsibilityFor
for Pharmacology
Pharmacology

MUPIROCIN (BACTROBAN)
Classification: Mupirocin is a topical antibiotic. • Caution parents that causative organisms are
Action: Mupirocin is used to treat impetigo caused by infectious by direct contact. Instruct them to wash
Staphylococcus aureus and Streptococcus pyogenes. their own hands before and after applying the
Pregnancy Risk Category: B ointment.
Dosage: Small amount applied three times a day to the • Although the lesions may begin to improve before
affected areas for 10 days duration 10 days have elapsed, urge parents to continue to use
Possible Adverse Effects: Erythema, dry skin, pruritus, the ointment to ensure eradication of the causative
burning, stinging (Karch, 2013) bacteria.
• Instruct parents to use caution if applying the ointment
Nursing Implications around the eyes because the ointment is irritating to
• Advise parents to wash the lesions with soap and water the eyes.
and pat dry before applying ointment to soften crusts
for better absorption.

An infection usually begins as a boil. It can spread to Assessment. Diphtheria is an illness that should be extinct be-
become a painful abscess or invade deeper body structures cause of available immunizations; however, it still occurs in iso-
such as joints and heart valves. Children who are identified lated outbreaks. Diphtheria bacilli invade and grow in the naso-
as having MRSA are isolated to help prevent the spread of pharynx of children, and produce an exotoxin (a potent protein
the bacteria to others. Vancomycin is the drug of choice for poison) that causes massive cell necrosis and inflammation. The
treatment of hospital-based lesions because the bacteria are necrosing material lends itself well to the growth of the bacilli,
still susceptible to its design. Trimethoprim-sulfamethoxazole so the bacilli reproduce rapidly. The inflammation and necros-
is commonly used with community infections. Use strict ing cells form a characteristic gray membrane on the nasophar-
standard infection precaution measures when caring for a ynx. This may extend up into the nose and down into the major
child with an MRSA infection. Teach children the best way bronchi, causing a purulent nasal discharge and a brassy cough.
to prevent staphylococcal infections of the skin is good hand The toxin is absorbed from the membrane surface and spreads
washing and reporting skin wounds to a health care provider systemically by the bloodstream to affect major organs, such as
before an open wound can become infected (Upshaw-Owens the heart and nervous system. If untreated, myocarditis with
& Bailey, 2012). heart failure and conduction disturbances may occur. Central
nervous system involvement can include severe neuritis with pa-
Scalded Skin Disease ralysis of the diaphragm and pharyngeal and laryngeal muscles.
Scalded skin disease (Ritter disease) is a staphylococcal infection The diagnosis of diphtheria is made based on clinical appear-
seen primarily in neonates. Newborns develop rough-textured ance and on a throat culture, which reveals the presence of the
skin and general erythema, especially on areas that encounter diphtheria bacilli (Ogle & Anderson, 2012).
friction. Large bullae (vesicles) filled with clear fluid form. The Therapeutic Management. Treatment involves intravenous
epidermis separates in large sheets and desquamates, leaving a administration of antitoxin in large doses. In addition, chil-
raw, red, glistening, and scalded-looking surface. Children need dren are given penicillin or erythromycin intravenously.
intensive intravenous antibiotic therapy to survive this extreme Complete bed rest is crucial during the acute stage of the
infection (Neylon, O’Connell, Sleven, et al., 2010). illness. Droplet precautions must be followed until cultures
are negative. Children need careful observation at all times to
Other Bacterial Infections prevent airway obstruction. If obstruction occurs, endotra-
Diphtheria cheal intubation may be necessary.
Because the diphtheria vaccine is included in routine
• Causative agent: Corynebacterium diphtheriae (Klebs–Löffler immunizations for infants, diphtheria is almost extinct in the
bacillus) United States. However, isolated instances do occur, and when
• Incubation period: 2 to 6 days they do, prompt recognition and treatment are necessary.
• Period of communicability: Rarely more than 2 weeks
to 4 weeks in untreated persons; 1 to 2 days in children Whooping Cough (Pertussis)
treated with antibiotics
• Mode of transmission: Direct or indirect contact with • Causative agent: Bordetella pertussis
respiratory secretions • Incubation period: 5 to 21 days
• Immunity: Contracting the disease gives lasting natural • Mode of transmission: Direct or indirect contact
immunity • Period of communicability: Greatest in catarrhal
• Active artificial immunity: Diphtheria toxin given as part (respiratory illness) stage
of diphtheria, tetanus, and pertussis (DTaP) vaccine • Immunity: Contracting the disease offers lasting natural
• Passive artificial immunity: Diphtheria antitoxin immunity

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 1274 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

• Active artificial immunity: Pertussis vaccine given as part Prevention. Little passive immunity is transferred across the
of DTaP vaccine placenta, so children in their early months are particularly
• Passive artificial immunity: Pertussis immune serum susceptible to the disease. It is the reason that, at 2 months,
globulin the pertussis vaccine (in the form of the DTaP vaccine) is
Pertussis is a serious disease of childhood but, like diph- one of the first immunizations scheduled (Atkinson, Wolfe,
theria, has become quite rare in the United States because & Hamborsky, 2011).
of required immunizations. It still occurs sporadically and is
actually making a comeback in some locales, particularly with What if...43.2 An adolescent who has
underimmunized adolescents (Spratling & Carmon, 2010). pertussis vomits after an episode of coughing.
Assessment. Pertussis manifests itself in three steps: the Should you urge him to try to eat again immediately,
catarrhal stage, the paroxysmal stage, and the convalescent or do you think he would be too nauseated to do so?
stage. The catarrhal stage begins with upper respiratory
symptoms such as coryza, sneezing, lacrimation, cough, and
a low-grade fever, symptoms subtle enough they may at first Anthrax
be mistaken for those of a common cold. This first period
lasts 1 to 2 weeks. • Causative agent: Bacillus anthracis, a bacteria
The paroxysmal stage lasts 4 to 6 weeks. During this time, • Incubation period: 1 to 7 days (inhalational), 1 to 12 days
the cough changes from a mild one to paroxysmal, involv- (cutaneous), 1 to 7 days (gastrointestinal)
ing 5 to 10 short, rapid coughs, followed by a rapid inspi- • Mode of transmission: Originally contracted from contact
ration, which causes the “whoop” or high-pitched crowing with the feces of infected cows or sheep; not transmissible
sound of whooping cough. Children are in obvious distress from person to person
while coughing. They may become cyanotic or red faced, • Immunity: Unstudied
and their nose may drain thick, tenacious mucus. They often • Active artificial immunity: A vaccine is available for people
vomit after a paroxysm of coughing, and they feel exhausted in high-risk occupations, such as veterinarians, but it is not
afterward from the effort. recommended for children
During the convalescent stage, there is a gradual cessation • Passive artificial immunity: Not available
of the coughing and vomiting. During the next year, how- Anthrax is an acute infectious disease that is contracted
ever, if children develop an upper respiratory infection, they from exposure to the anthrax bacteria or its spores. As the
may again have a return of the paroxysmal coughing with organism grows inside the human body, a toxin is produced
vomiting. that causes the bulk of the symptoms. Children, like adults,
Pertussis is diagnosed by its striking symptoms, although may be affected by all three clinical forms: cutaneous, inhala-
in children younger than 6 months of age, the “whoop” of the tional, or gastrointestinal.
cough may be absent, making it more difficult to diagnose. Inhalational anthrax has a mortality rate of over 90%. It
The B. pertussis bacillus may be cultured from nasopharyngeal begins with a brief prodromal period of flulike symptoms,
secretions during the catarrhal and paroxysmal stages. followed shortly by dyspnea, severe systemic shock, and
The white blood cell count, particularly the lympho- marked evidence of mediastinal widening and pleural effu-
cyte count, is markedly increased to as high as 20,000 to sion on X-ray. Because it can be fatal and spreads through
30,000/mm3 (normal levels are 5,000 to 10,000/mm3). coughing, anthrax has been proposed as bacteria that could
Therapeutic Management. Children with pertussis are main- be used in bioterrorism (Woodward, 2012).
tained on bed rest until the paroxysms of coughing subside. Cutaneous anthrax is characterized by a skin lesion that
Urge parents to keep them secluded from environmental fac- begins as a papule, then passes through a vesicle stage, to a
tors, such as cigarette smoke and dust, and to avoid strenuous painless depressed black eschar. Fever, malaise, headache,
activities because these initiate coughing episodes. Nutrition and regional swollen lymph nodes may accompany the skin
may become a problem if the child is constantly coughing lesion. The mortality of cutaneous anthrax is as low as 1%
and vomiting. As a rule, frequent small meals are vomited less with antibiotic therapy.
than larger meals and so should be encouraged. Gastrointestinal anthrax is contracted by eating under-
A full 10-day course of erythromycin or azithromycin may cooked meat infected with the organism. The child develops
be prescribed because these drugs have the potential to shorten severe abdominal pain, fever, bloody diarrhea, and septicemia.
the period of communicability and may shorten the duration The mortality rate for this form is about 25%.
of symptoms. Droplet precautions are used until 5 days after If exposed to anthrax, prophylaxis with ciprofloxacin
a child starts antibiotic therapy. Complications of pertussis (Cipro) for those older than 18 years of age and doxycycline
include alkalosis and dehydration caused by vomiting and for younger patients are the drugs of choice. Drug therapy is
pneumonia, atelectasis, or emphysema from plugged bron- continued for 60 days because of the potential persistence of
chioles. Epistaxis, subconjunctival and subarachnoid bleed- and difficulty in killing spores.
ing, or seizures from asphyxia as a result of severe paroxysms Tetanus (Lockjaw)
of coughing may also occur. Infants with pertussis may be
admitted to a health care facility for observation because they • Causative agent: Clostridium tetani
become dehydrated or may have such tenacious secretions • Incubation period: 3 days to 3 weeks
that they need airway suction. For safety, place an intercom • Period of communicability: None
in the infant’s room so you can identify severe coughing even • Mode of transmission: Direct or indirect contamination of
when not in the room. a closed wound

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1275

• Immunity: Development of the disease gives lasting natural than 10 years since the last injection, no booster or antitoxin
immunity management is needed at the time of the wound.
• Active artificial immunity: Tetanus toxoid contained in If a child’s immunization record cannot be obtained, or
DTaP vaccine if it has been more than 10 years since the child received a
• Passive artificial immunity: Tetanus immune globulin booster injection or an initial injection for tetanus, a child
Tetanus, a highly fatal disease if untreated, is caused by will be treated with a booster injection and tetanus immune
an anaerobic, spore-forming bacillus found in soil and the globulin. The booster injection provides tetanus antigen
excretions of animals. It enters the body through an open to the child. The booster injection will cause the body to
wound. If the wound is deep, such as a stab wound, where “remember” how to make tetanus antibodies so, by the time
the distal end of the wound is shut off from an oxygen the invading tetanus organisms from the wound have passed
source, tetanus bacilli begin to reproduce. The organism may their long incubation period (3 days to 3 weeks), the child
also enter through a burn site, which crusts, thus creating will have antibodies in the system prepared to eradicate the
an anaerobic environment. As the bacilli grow, they produce organisms. If the initial immunizations were incomplete
exotoxins that cause the disease symptoms by affecting the or are unknown, in addition to tetanus antigen, the child
motor nuclei of the central nervous system (Afshar, Raju, will also receive the passive antibodies included in tetanus
Ansell, et al., 2011). immune globulin (Lee & McCallin, 2011).
The entrance site of the bacillus does not appear infected Lyme Disease
(no pus or reddened area is present unless a secondary
infection also exists). After the incubation period, the exo- • Causative agent: Borrelia burgdorferi, a spirochete
toxins have developed to such an extent, however, that they • Incubation period: 3 to 30 days
are capable of disrupting the nervous system. In the United • Period of communicability: Not communicable from one
States, most children are vaccinated against tetanus. In devel- person to another
oping countries, it continues to have a high incidence, caused • Mode of transmission: Deer tick
by infection of an entry point such as the umbilical cord at • Active artificial immunity: Lyme disease vaccine
birth (Bairwa, Rajput, Khanna, et al., 2012). • Passive artificial immunity: Immune globulin
Assessment. The first symptoms that are noticeable are stiff- Lyme disease is caused by a spirochete, B. burgdorferi,
ness of the neck and jaw (lockjaw). Within 24 to 48 hours, which is transmitted by a tick frequently carried on deer
muscular rigidity of the trunk and extremities develops. The (Esposito, Bosis, Sabatini, et al., 2013). The disease is the
back becomes arched (opisthotonos), the abdominal mus- most frequently reported vector-borne infection in the United
cles are stiff and boardlike, and the face assumes an unusual States, occurring most often in the summer and early fall and
appearance, with wrinkling of the forehead and distortion of on the east coast (it is named after the city in Connecticut
the corners of the mouth (a “sardonic grin” sign). Any stim- where it was first identified). A vaccine for the disease is not
ulation, such as a sudden noise, a bright light, or a touch, currently available, because the manufacturer ceased produc-
causes painful, paroxysmal spasms. The sensorium is clear tion in 2002, due to low demand (CDC, 2011b).
throughout the course of the disease, so the child is aware of Almost immediately after a tick bite, an erythematous
the pain associated with the muscle spasms. As these spasms papule is noticeable at the site, which spreads over the next 3 to
begin to include the larynx, respiratory obstruction and death 30 days (the incubation period) to become a large, round ring
by asphyxiation can occur. with a raised swollen border (erythema chronicum migrans)
(Fig. 43.13). This is followed by systemic involvement that
Therapeutic Management. A child needs to be cared for in can lead to cardiac, musculoskeletal, and neurologic symp-
a quiet, stimulation-free room with total parenteral nutri- toms. Cardiac involvement may be so severe that it includes
tion, sedation, and a muscle relaxant to prevent aspiration heart block from atrioventricular conduction abnormalities.
from muscle spasms. If the wound is filled with necrotic tis- Neurologic symptoms commonly include stiff neck, headache,
sue, it may be debrided to ensure no secondary infections
arise. Tetanus immune globulin (human) is administered to
supply passive antitoxins; parenteral penicillin G or erythro-
mycin will be administered to reduce the number of grow-
ing forms of the bacillus. A child may need to be intubated
and mechanical ventilation begun to maintain respiratory
function.
Prevention. Tetanus is a serious disease, but it can be pre-
vented through active immunization and suitable booster
immunizations. Children routinely receive tetanus immuni-
zation as part of routine DTaP immunization with a booster
dose at school age; thereafter, they should receive a booster
dose every 10 years. At the time of a wound, the wound site
should be cleaned well with soap and water and a suitable
antiseptic. It should not be sutured but should be left open
to heal by secondary intention to reduce the possibility of an
anaerobic pocket forming in the wound. If the child received FIGURE 43.13 The rash of Lyme disease. (© Larry Mulvehill/
basic immunization against tetanus and it has been fewer Science Source/Photo Researchers.)

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 1276 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

BOX 43.7 Nursing Care Planning to Empower a Family

TIPS FOR AVOIDING EXPOSURE TO LYME DISEASE

Q. Marty’s father tells you, “My children love to play in the woods, but I’m so afraid they’ll get Lyme disease. What can
I do to protect them?”
A. Here are some suggestions to help reduce the risk of exposure:

• Wear protective clothing when hiking or playing in • Inspect skin for ticks thoroughly after hiking or play-
wooded areas, such as long sleeves, high necklines, and ing in wooded areas. Remove any ticks found with
long slacks. Tuck bottom of slacks into socks or boots. tweezers.
• Wear light-colored clothing so any tick present on • Report any area of inflammation that might be a tick
clothing can be readily observed. bite to a health care provider for early diagnosis.

and cranial nerve palsy. Musculoskeletal symptoms include Rocky Mountain spotted fever is the second most com-
painful swollen arthritic joints, particularly in the knee. mon rickettsial disease seen in the United States. It is most
Amoxicillin is administered at the time of the bite to prevalent in the western United States and is transmitted by
young children, whereas doxycycline is given to those older tick bites (Graham, Stockley, & Goldman, 2011).
than 8 years of age. Encourage parents to inspect the skin of It occurs most often during the spring and early summer,
children who have been playing in wooded areas for tick bites when ticks are most plentiful. A reddened area develops at the
to help identify the disorder before debilitating symptoms site of the tick bite. In 2 to 8 days, a typical rash, persistent head-
occur (CDC, 2011b). Other suggestions for avoiding Lyme ache, fever (as high as 104°F [40°C]), and mental confusion
diseasee aare
re show
shown in Box 43.7. begin. The rash is distinctive, beginning with reddened macules,
which then changes to petechiae. It begins on the wrists and
ankles, then spreads up the arms and legs onto the trunk. Unlike
OTHER
OT
OTH
THER
T HER
H ER
ER IIN
INFECTIOUS PATHOGENS most rashes, it can cover the palms and soles (Fig. 43.14).
In untreated children, symptoms worsen to include central
Rickettsial Diseases nervous system involvement (stiff neck and seizures) and cardiac
and pulmonary symptoms such as heart failure and pneumonia.
Rickettsiae are organisms that resemble viruses both in size Rocky Mountain spotted fever was a serious childhood
and in their inability to reproduce except inside the cells illness before antibiotic therapy was available, and it still has
of a host organism. They reproduce by fission, however, as the potential to be serious if the symptoms are not reported
bacteria do; like bacteria, they are complete organisms con- when they first occur. First-line therapy is with doxycycline
taining both RNA and DNA. They multiply inside ticks, lice, for 7 to 10 days, and should be initiated within the first
mites, or fleas (arthropods) without causing disease. They 5 days of the appearance of symptoms. Caution parents to
are transmitted to humans through the bite or feces of the administer the drug for the full course of therapy to ensure
infected arthropod. An exception is Q fever, which is spread disease eradication and to prevent the risk of complications.
by droplet infection. All rickettsial diseases include fever, trig-
ger an immune response, and almost all include a rash caused
by rickettsial multiplication in the endothelial cells of small
blood vessels.

What if...43.3 Marty’s mother tells you

she’s always been afraid her children would contact
Lyme disease because, in the winter, the family picks both
limes and lemons in Florida. Could you assure her Marty
will never contract Lyme disease while in an orchard
picking fruit?

Rocky Mountain Spotted Fever

• Causative agent: Rickettsia rickettsii

• Incubation period: 3 to 12 days
• Period of communicability: Not communicable from one
person to another
• Mode of transmission: Wood, dog, or rabbit tick FIGURE 43.14 The typical rash of Rocky Mountain spotted
• Active artificial immunity: Rocky Mountain spotted fever. (Courtesy of Stuart Starr, MD, The Children’s Hospital of
fever vaccine Philadelphia.)

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 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1277

TABLE 43.3 Common Parasitic Infections

Infection Organism Symptoms Treatment

Pediculosis Head lice Small, white flecks on hair shaft (nits or eggs Wash hair with shampoo such as lindane
capitis of lice); extreme pruritus (Kwell) and comb nits from hair with
fine-toothed comb. Wash bed sheets
and recently worn clothes; vacuum
pillows, mattresses, or other items un-
able to be washed. Teach children not to
exchange combs, hair barrettes, or other
personal items.

Pediculosis Pubic lice Same as for head lice except on pubic hair Same as head lice.

Scabies Female mite Black burrow filled with mite feces 1–2 in. Caution that adolescent groin infestations
(Acarus scabiei ) long, usually between fingers and toes, might be spread by physical intimacy.
on palms, or in axilla or groin Wash area with lindane (Kwell) lotion or
permethrin (Elimite).

Psittacosis embarrassed when they learn their child has one of these
illnesses. You can reassure them that these infestations could
Psittacosis, caused by Chlamydia psittaci, is a disease trans- happen to any child (Box 43.8).
mitted to children through the inhalation of dried secre-
tions of birds, such as parakeets, macaws, parrots, cockatiels, Helminthic Infections
turkeys, and ducks. Although the bird does not appear ill,
children develop symptoms of an upper respiratory infection, Helminths are pathogenic or parasitic worms. They include
such as pneumonia, possibly a low-grade fever, a dry cough, roundworms (nematodes), flukes (trematodes), or tapeworms
weakness, an enlarged spleen, and anorexia out of propor- (cestodes). Most helminths begin life when the eggs or lar-
tion to the fever. The course of the disease is as long as 3 to vae are eliminated in the feces or urine of humans. They are
4 weeks. Treatment is with an antibiotic such as doxycycline then transmitted to the oral cavity by contaminated foods or
(Stewardson & Grayson, 2010). hands. Because children tend to be careless about washing
their hands before eating or tend to suck their thumbs, it
Parasitic Infections makes them prone to these infections (Rote, 2012).
Parasites are organisms that live on and obtain their food Roundworms (Ascariasis)
supply from other organisms. Although many of these
can cause illness, ones frequently associated with children The roundworm parasite lives in the intestinal tract. Larvae,
include head lice and scabies (Table 43.3). Parents are often which hatch from the ingested eggs, penetrate the intestinal

BOX 43.8 Nursing Care Planning Based on Effective Communication

When Marty’s 6-year-old brother Joshua visits him, you notice Joshua has scratch marks on
his neck and forehead. His hair shafts are covered by sandlike particles. You suspect he has
pediculosis capitis or head lice.

Less Effective Communication More Effective Communication

Nurse: Mrs. Ireland, I’m wondering if you’ve noticed these Nurse: Mrs. Ireland, I’m wondering if you’ve noticed these
sandlike particles in your son’s hair. sandlike particles in your son’s hair.
Mrs. Ireland: Well, you know boys. They don’t always Mrs. Ireland: Well, you know boys. They don’t always
wash well. wash well.
Nurse: I’m concerned they may be the eggs of Nurse: I’m concerned they may be the eggs of head lice.
head lice. Mrs. Ireland: We’re not that poor. Don’t insult us.
Mrs. Ireland: We’re not that poor. Don’t insult us. Nurse: Let’s talk about head lice, and how easy it is for
Nurse: Like you said, it’s probably something else. anyone to get them.

The previous scenario is an example of what can happen if people believe the myth that communicable
diseases are always associated with poor hygiene or poverty. Head lice can be spread easily in locker
rooms or classrooms, so any child can contract them.

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 1278 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

wall and enter the circulation. From there, they may migrate symptoms such as diarrhea, weight loss, abdominal cramps,
to any body tissue. Children develop a loss of appetite and and nausea after an incubation time of 3 to 25 days. Diagnosis
perhaps nausea and vomiting. Intestinal obstruction may is made by history and recognition of the mature form of the
occur from a mass of roundworms in the intestine. Ascariasis organism in the stool or on duodenal aspiration. Therapy is
can be prevented by the sanitary disposal of feces to prevent with metronidazole (Flagyl) for 7 days (Wright, 2012).
contamination of the soil. A single dose of an anthelmintic
such as pyrantel pamoate (Antiminth) controls the infection. Fungal Infections
Hookworms Fungi are larger than bacteria; some are unicellular (yeasts),
but generally they are multicellular (molds). Deep mycoses
Hookworm eggs, like roundworm eggs, are found in invade internal organs. Transmission is by the inhalation of
human feces. They enter children’s bodies through the skin spores. Subcutaneous mycoses invade the skin, subcutaneous
and then migrate to the intestinal tract, where they attach tissue, and bone. Infections usually occur from introduction
themselves onto the intestinal villi and suck blood from the of the fungi into a wound. Superficial mycoses invade only
intestinal wall to sustain themselves. If a great number of the hair, skin, or nails.
hookworms are present, severe anemia may result. Treatment
is with anthelmintics. Children may also need therapy for Superficial Fungal Infections
the anemia.
Four superficial fungal infections seen frequently in children
Pinworms are tinea cruris, pedis, capitis, and corporis.
Pinworms are small, white, threadlike worms that live in the Tinea Cruris. Tinea cruris (jock itch) occurs on the inner
cecum. At night, the female pinworm migrates down the thighs and scrotum. The area appears reddened and is very
intestinal tract and out of the anus to deposit eggs on the skin pruritic. Local application of clotrimazole (Lotrimin) or
in the anal and perianal region. The movement of the worms econazole (Spectazole) liquid or powder destroys the infection
causes the anal area to itch, and the child will awaken at night (Karch, 2013).
crying and scratching. Some of the eggs are then carried from
Tinea Pedis. Tinea pedis (athlete’s foot) produces pruritic,
the child’s fingernails to the mouth. After being ingested, they
pinpoint vesicles with fissuring between the toes and on the
hatch in the child’s intestinal tract, and the cycle is repeated
plantar surface of the foot. It is treated with liquid prepara-
(Wang, Hwang, & Chen, 2010).
tions of an antifungal agent such as clotrimazole (Lotrimin).
The worms are large enough that they can be seen if the
child’s buttocks are separated. Pressing a piece of cellophane Tinea Capitis. Tinea capitis (ringworm of the scalp) begins as
tape against the anus, then inspecting it under a microscope the infection of a single hair follicle but then spreads rapidly
will generally reveal pinworm eggs. in a circular pattern to produce a lesion approximately 1 in.
Treatment is with a single dose of mebendazole (Vermox) in diameter. The hairs involved in the lesion generally break
or pyrantel pamoate (Antiminth) (Lee & McCallin, 2011). off and the circle becomes filled with dirty-appearing scales.
Underclothing, bedding, towels, and nightclothes should be Treatment is with an antifungal such as griseofulvin,
washed before reuse. In addition, all family members need which is given orally. Adolescents should be cautioned not
to be treated for pinworm infestation because the worms are to consume alcohol while taking this drug because this may
easily transmitted from person to person. Teach children to cause tachycardia. Safety of the drug during pregnancy is
avoid nail biting and to wash their hands before food prep- not established. Caution children to avoid strong sunlight
aration or eating to avoid transfer of pinworm eggs and to during therapy because photosensitivity may occur (Gupta &
prevent this type of infection. Drummond-Main, 2013).
Tinea capitis is not as contagious as was once assumed.
Protozoan Infections Children do not need to have their head shaved or be kept
home from school, although they should be cautioned not
Protozoa are unicellular organisms. They absorb fluid through to exchange towels, combs, or other potential fomites. The
their cell membrane and can move from place to place by course of the disease can be lengthy, perhaps as long as
pseudopod, flagella, or cilia action. They are most pathogenic 3 months, before all lesions have faded (Petros, 2010).
in the gastrointestinal, genitourinary, and circulatory systems.
Some protozoa reproduce by simple binary fission, whereas Tinea Corporis. Tinea corporis (ringworm of the body) is an
other forms have complex life cycles. They have the ability to infection of the epidermal layer of the skin. It presents as a scaly
form cysts or surround themselves with a membrane, which ring of inflammation with a clear area in the center, which
makes them resistant to destruction. can occur anywhere on the body (Fig. 43.15). Treatment
is with a topical antifungal agent such as clotrimazole
Giardiasis (Lotrimin).
Giardia lamblia is a protozoan infection responsible for Candidiasis
epidemic outbreaks of diarrhea, particularly in travelers to
Europe and in day care centers in the United States (Karon, Candida albicans is the fungus responsible for candidal
Hanni, Mohle-Boetani, et al., 2010). (monilial) infections. Candidal organisms grow in the vagina
Transmission occurs when the child ingests the cysts of of many adult women and adolescents (candidal vaginitis)
the organism from unclean hands. The cysts then develop in (see Chapter 47). Newborns born vaginally may develop an
the intestine into the mature form of the organism, causing infection of the mucous membrane of the mouth (thrush

PILLITTERI_E7_CH43.indd 1278 7/8/13 6:37 AM

 CHAPTER 43 Nursing Care of a Family When a Child Has an Infectious Disorder 1279

with the lesions rather than being washed away immediately by

a feeding. For diaper rash, a nystatin ointment is prescribed.
There is a tendency to think of thrush as a common,
almost expected disease of infants. Candidiasis can become a
systemic infection, however, and it can spread easily through
a newborn population such as a nursery or child care facility
(Antaya, 2010).

What if...43.4 You are particularly

interested in exploring one of the 2020 National
Health Goals related to infectious diseases in children
(see Box 43.1). What would be a possible research topic
to explore pertinent to this goal that would be applicable
to Marty and his family and that would also advance
FIGURE 43.15 Ringworm (tinea corporis). The fungus evidence-based practice?
spreads rapidly, producing a circular, ringlike lesion. (© SPL/
Science Source/Photo Researchers.)
KEY POINTS FOR REVIEW
or oral candidal infection) from exposure at birth. Thrush
is characterized by white plaques on an erythematous base ● The incubation period of an infectious disease is the time
on the buccal membrane and the surface of the tongue. It between the invasion of an organism and the onset of
resembles a milk curd left from a recent milk feeding. Thrush symptoms. The prodromal period is the time between
plaques do not scrape away, however, whereas milk curds do. the beginning of nonspecific symptoms and specific ones
The infant’s mouth is painful and he or she may not suck well and the time when children are most infectious. Illness
due to the inflammation and local pain. is the stage during which specific symptoms are evident.
C. albicans can also cause a severe, bright red, sharply cir- The convalescent period is the interval between the time
cumscribed diaper-area rash (Fig. 43.16). The rash is marked symptoms begin to fade and the time the child returns to
by its intense color, satellite lesions are usually present, and baseline health.
it does not improve with usual diaper rash measures, such as ● The chain of infection depends on the presence of a
application of a protective ointment, frequent changing of reservoir, a portal of exit, a mode of transmission, a
diapers, or exposure to air. portal of entry, and a susceptible host. To reduce the
Nystatin is an example of an effective antifungal drug (Karch, spread of infection, use standard infection precautions
2013). For oral candidiasis, it is generally administered by mouth to break the chain of infection. Transmission-based
approximately four times a day. Teach parents to drop the liq- precautions—airborne, droplet, and contact—also
uid into the mouth after feedings so it will remain in contact may be necessary.
● Common viral infections of childhood include exanthem
subitum (roseola), rubella (German measles), measles
(rubeola), chickenpox (varicella), herpes zoster, erythema
infectiosum (fifth disease), pityriasis rosea, mumps
(epidemic parotitis), infectious mononucleosis, and
cat-scratch disease. Other important viral infections
include poliomyelitis (now almost extinct), herpesvirus
infections, verrucae (warts), rabies, and West Nile
virus disease.
● Common streptococcal diseases include scarlet fever and
impetigo. Staphylococcal infections include furunculosis
(boils), cellulitis, and scalded skin disease. Outbreaks
of diphtheria, whooping cough (pertussis), and tetanus
(lockjaw) still occur.
● Common tick-borne diseases are Rocky Mountain
spotted fever and Lyme disease. Parasitic infections are
pediculosis capitis (head lice), pediculosis pubis, and
scabies. Helminthic infections include roundworms,
hookworms, and pinworms. Fungal infections are tinea
capitis and tinea corporis, both of which are forms of
ringworm.
● Teaching parents and children about infection control
measures and the need for keeping immunizations up to
FIGURE 43.16 Monilial (candidiasis) diaper rash. Note the date is essential not only for reducing the risk of infec-
intense red color of the rash and the satellite lesions. (© Custom tious disorders in children but also for meeting QSEN
Medical Stock Photograph.) competencies and best meeting the family’s total needs.

PILLITTERI_E7_CH43.indd 1279 7/8/13 6:37 AM

 1280 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children With Physiologic Disorders

CRITICAL THINKING CARE STUDY Bairwa, M., Rajput, M., Khanna, P., et al. (2012). India is on the way
forward to maternal and neonatal tetanus elimination! Human Vaccines

 arbie is a 10-year-old you meet while work-

ing as a nurse at a resident summer camp. Both her
& Immunotherapeutics, 8(8), 1129–1131.
Beach, R., & Thalange, N. (2013). Infectious disease & immunity. In
N. Thalange, R. Beach, D. Booth, et al. (Eds.), Essentials of paediatrics
forearms and lower legs have several papular lesions (2nd ed., pp. 231–246). Philadelphia, PA: Elsevier/Saunders.
that feel very itchy and are surrounded by erythema; a Centers for Disease Control and Prevention (2011a). A polio-free U.S.
number have honey-colored drainage and some crust- thanks to vaccine efforts. Washington, DC: Author.
Centers for Disease Control and Prevention (2011b). Preventing tick bites.
ing. Four days ago was “sleep out,” day so she spent the
Atlanta, GA: Author.
niight
h iin
night n a tent wi ith
withh th
hree ffriends
three riend
i ds b ut d
but idn’t
’ sleep
didn’t l wellll Centers for Disease Control and Prevention. (2012). Rubella: Be sure your
because “mosquitoes bit me all night.” Barbie’s parents child gets vaccinated. Washington, DC: Author.
return from their vacation to be certain their daughter Daley, M. F., O’Leary, S. T., & Nyquist, A. C. (2012). Immunization. In W.
is all right, but they seem angry and frustrated. The Hay, M. Levin, R. Deterding, et al. (Eds.), Current diagnosis & treatment
mother
motherh tells
telllls you, “We
“W thought
thou
h ght h camp would ld b
bee a good
good d pediatrics (21st ed., pp. 254–288). New York, NY: McGraw-Hill/Lange.
experience for Barbie to separate her from a boyfriend Donohue, J. G., Kieke, B. A., Gargiullo, P. M., et al. (2010). Herpes
she likes a lot but we have qualms about that now. zoster and exposure to the varicella zoster virus in an era of varicella
Look at her; she’ll probably end up with scars from this.” vaccination. American Journal of Public Health, 100(6), 1116–1122.
Duval, L. (2010). Infection control 101. Nephrology Nursing Journal,
1. What do you suspect is the cause of the scattered lesions? 37(5), 485–489.
2. Gi
Given
Give
ven
n how
how impetigo
impe
im peti
tigo
go is
is transmitted
tran
transm
smit
itte
tedd to others,
oth
ther
ers,
s, what
wha
hatt im
impl
implica-
plic
ica-
a- Esposito, S., Bosis, S., Sabatini, C., et al. (2013). Borrelia burgdorferi
tions does its presence have for infection control practices infection and Lyme disease in children. International Journal of
in the camp setting? Infectious Disease, 17(3), e153–e158.
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than those she received as an infant because her mother be- syndrome. Lancet Neurology, 9(6): 634–642.
Graham, J., Stockley, K., & Goldman, R. D. (2011). Tick-borne illnesses:
lieves the danger of vaccines is higher than contracting“simple
contracting “simple
A CME update. Pediatric Emergency Care, 27(2), 141–117.
childhood infections”? Would immunization have prevented
Gupta, A. K., & Drummond-Main, C. (2013). Meta-analysis of randomized,
Barbie from contracting impetigo? Would you recommend she controlled trials comparing particular doses of griseofulvin and terbinafine
receive routine immunizations now or, at 10 years of age, is she for the treatment of tinea capitis. Pediatric Dermatology, 30(1), 1–6.
no longer in much danger from common contagious illnesses? Heyman, P., Thoma, B. R., Marié, J. L., et al. (2012). In search for factors
that drive hantavirus epidemics. Frontiers in Physiology, 2(3), 237.
Jackson, A. (2011). Rabies in the critical care unit: Diagnostic and therapeutic
approaches. The Canadian Journal of Neurological Sciences, 38(5), 689–695.
Patient Scenario Karch, A. M. (2013). 2013 Lippincott’s nursing drug guide. Philadelphia,
The Sukioto Family PA: Lippincott Williams & Wilkins.
Karon, A. E., Hanni, K. D., Mohle-Boetani, J. C., et al. (2010). Giardiasis
Read about the Sukioto family, a family whose outbreak at a camp after installation of a slow-sand filtration water-
adolescent has an infectious disease, then answer the treatment system. Epidemiology and Infections, 139(5), 713–717.
questions to further sharpen your skills and grow Katz, B. Z. (2013). Infectious mononucleosis & other Epstein-Barr
more familiar with NCLEX-type questions related to Virus associated lymphoproliferative disorders. In E. T. Bope &
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Lam, J. M. (2010). Characterizing viral exanthems. Pediatric Health, 4(6),
Answers and Rationales 623–635.
Lee, B., & McCallin, T. (2011). Microbiology & infectious disease. In
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Visit http://thePoint.lww.com Levin, M. J., & Weinberg, A. (2012). Infections, viral & rickettsial.
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