PEDIATRIC UPDATE
PEDIATRIC INFECTIOUS DISEASES Author: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, Boston, MA Section Editors: Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P, and Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN
Earn Up to 8.5 CE Hours. See page 174. mergency care of the sick child can be daunting. Manifestations of infectious diseases in the pediatric population are multifaceted, which can make the exact diagnosis difficult. Pediatric emergency nurses must immediately recognize the possible infectious disease causing the child’s symptoms to prevent a potential lethal outcome. If an infectious disease is suspected, the nurse should immediately initiate isolation precautions. If indicated, interventions to maintain adequate airway, breathing, oxygenation, circulation, and hydration of the sick child should be initiated. The nurse should stabilize the child first and then identify the diagnosis and provide definitive care (Table). Fever in children is the most common illness presentation. Emergency nurses must be highly vigilant when caring for pediatric patients who present with fever (≥ 38°C [≥ 100.4°F]). Nurses should assess for respiratory distress, tachycardia, tachypnea, abnormal vital signs, fever, nonblanchable rash, and stiff neck. Included in the assessment should be mouth or stool malodors, upper airway accessory muscle retractions, wheezing, abnormal noises, shrill or weak cry, sore throat, abnormal posturing, bulging, or depressed anterior fontanelle in children. Nurses should assess for vomiting, diarrhea, lethargy, pallor, mottling, cyanosis, capillary refill greater than 2 seconds, skin tenting, petechiae, no tears with crying, or dry mucous membranes. Other concerns include decreased urine output, decreased intake by mouth, extremity swelling, sores in the mouth, redness of the eyes, peeling of the hands or feet, or any subtle change in neurologic behavior or seizures. The child may exhibit changes in sleep patterns, crying, an inability to be consoled, feeding difficulties, or changes in urine or bowel
E
Patricia A. Normandin, Member, Massachusetts ENA Beacon Chapter, is Emergency Department Staff Nurse, Tufts Medical Center and Northeastern University, Boston, MA; Adjunct Nursing Faculty, Brigham & Women's Hospital and Massachusetts General Hospital, Institute of Health Professions, Boston, MA; and Term Lecturer, Site Clinical Instructor, Boston Children's Hospital, Boston, MA. For correspondence, write: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN; E-mail: [email protected] J Emerg Nurs 2015;41:160-1. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.12.008
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movements. It is crucial that all emergency nurses know pediatric growth and development behaviors to ensure prompt identification of real pediatric emergencies. Children with chronic lung conditions such as asthma are at increased risk of rhinoviruses, enterovirus D68, respiratory syncytial virus, and respiratory infections. The child’s age and symptoms, as well as common seasonal illnesses, should be included when considering possible diagnoses. It is important to obtain an accurate immunization history because unimmunized or under-immunized children are vulnerable to infectious disease. A normal temperature or hypothermia does not exclude sepsis in children. Sepsis red flags in children include fever in neonates (b 28 days old), infants younger than 3 months, children with chronic medical conditions, immunocompromised children, and children younger than 2 years with fever of unknown origin. 1–3 Interventions
Pediatric patients who present with potential infectious diseases need to be immediately isolated and appropriate infection control precautions (standard, droplet, contact) and interventions initiated. Nursing care includes continuous monitoring of oxygen saturation, heart rate, respirations, temperature, and intermittent blood pressure. Supportive measures to resolve hypovolemia and electrolyte imbalances should be initiated. Measures to maintain airway and breathing by positioning the child in an upright position of comfort should be instituted if needed, and administration of oxygen via a 100% non-rebreather mask or “blow-by” oxygen should be considered. It might be necessary to suction the nares and mouths of children with secretions, with the understanding that infants are obligatory nose breathers for the first 6 months of life. If capillary refill is greater than 2 seconds, and the child is showing signs of decompensation, immediately initiate a bolus of intravenous or intraosseous isotonic hydration, 20 mL/kg, administer rapidly using the syringe and stopcock method, usually over 5 to 10 minutes. Intravenous bolus interventions should be repeated up to 3 to 4 times to maintain circulation (until capillary refill is less than 2 seconds) by rapidly administering repeat boluses, 20 mL/kg over 5 to 10 minutes using the syringe and stopcock method to stabilize the child. Antipyretics should be administered as
VOLUME 41 • ISSUE 2
March 2015
Normandin/PEDIATRIC UPDATE
TABLE
Common signs and symptoms and possible differential diagnoses 1,2 Sign or symptom
Possible differential diagnoses
Fever
Bacterial meningitis, malaria, otitis media, septic arthritis, sinusitis, pneumonitis, Haemophilus influenzae type B, influenza, urinary tract infections, septicemia, Ebola, mumps, rabies, Lyme disease, herpes simplex viruses Bacterial meningitis, viral meningitis, chicken pox (varicella), coxsackievirus, diphtheria, erythema infectiosum (fifth disease), measles (rubeola), roseola, rubella (German measles), Rocky Mountain spotted fever, mononucleosis, community-acquired methicillin-resistant Staphylococcus aureus, toxic shock syndrome, hand-foot-andmouth disease, group A streptococcus, sexually transmitted diseases, herpes simplex virus Community-acquired methicillin-resistant Staphylococcus aureus, abscess, scalded skin syndrome, cellulitis, group A streptococcus, tetanus Respiratory infection/pneumonia in children, viral or bacterial gastrointestinal infections Rotavirus, gastrointestinal bacterial infections, gastrointestinal viruses, salmonella, Ebola (rare in children), norovirus Viral infection, bacterial infection, parasitic infection, antibiotic-associated diarrhea (Clostridium difficile), gastroenteritis, Escherichia coli, calicivirus, adenovirus Hemolytic uremic syndrome, rotavirus, E coli, shigella, campylobacter, salmonella, other enteropathogens Pneumonia, bronchiolitis, respiratory syncytial virus, upper respiratory infections, enterovirus D68, other enteroviruses, epiglottitis, rhinoviruses, tuberculosis Croup, pneumonia, pneumococcal infections, flu, upper respiratory infections, pertussis (whooping cough) Mononucleosis, flu, viral syndromes, septicemia, hepatitis, poliomyelitis
Rash
Soft-tissue infections Vomiting Vomiting and diarrhea Diarrhea Bloody diarrhea Respiratory distress including rapid breathing Cough Malaise, body aches, fatigue
It should be noted that symptoms overlap in many infectious diseases. A child with chronic infections should undergo a thorough evaluation by his or her pediatrician for undiagnosed underlying conditions such as cystic fibrosis, human immunodeficiency virus, genetic disorders, or malignant disorders.
needed to manage fever (aspirin should never be used because of the association of aspirin, viral infection, and Reye’s syndrome) and antibiotic therapy begun depending on the suspected diagnosis. If bacterial meningitis is suspected, antibiotics should be immediately administered regardless of whether diagnostic testing has been completed. Septic evaluation including blood tests, chest radiographs, and urine, blood, sputum, spinal fluid, and stool cultures should be completed. Preventative Measures and Patient Teaching
We must never forget that proper hand washing, as well as appropriate and thorough cleaning of all equipment after use, is the best way to prevent the spread of infection. The Centers for Disease Control and Prevention (www.cdc.gov) has many free important pediatric teaching tools for pediatric health care providers, parents, and child care providers. Nurses should share with parents and child care
March 2015
VOLUME 41 • ISSUE 2
providers the importance of maintaining their own up-todate immunizations, as well as those of the children. REFERENCES 1. Emergency Nurse Association. Emergency Nursing Pediatric Course Provider Manual. 4th ed., Des Plaines, IL: Emergency Nurse Association; 2014. 2. London ML, Ladewig PW, Ball JW, Bindler RC, Cowen KJ, eds. Maternal & Child Nursing Care. 3rd ed.Upper Saddle River, NJ: Pearson; 2011. 3. Centers for Disease Control and Prevention. Enterovirus D68 in the United States, 2014. http://www.cdc.gov/non-polio-enterovirus/outbreaks/EVD68-outbreaks.html. Accessed November 28, 2014
Submissions to this column are encouraged and may be sent to Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P [email protected] or Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN [email protected]
WWW.JENONLINE.ORG
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PEDIATRIC INFECTIOUS DISEASES Author: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, Boston, MA Section Editors: Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P, and Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN
Earn Up to 8.5 CE Hours. See page 174. mergency care of the sick child can be daunting. Manifestations of infectious diseases in the pediatric population are multifaceted, which can make the exact diagnosis difficult. Pediatric emergency nurses must immediately recognize the possible infectious disease causing the child’s symptoms to prevent a potential lethal outcome. If an infectious disease is suspected, the nurse should immediately initiate isolation precautions. If indicated, interventions to maintain adequate airway, breathing, oxygenation, circulation, and hydration of the sick child should be initiated. The nurse should stabilize the child first and then identify the diagnosis and provide definitive care (Table). Fever in children is the most common illness presentation. Emergency nurses must be highly vigilant when caring for pediatric patients who present with fever (≥ 38°C [≥ 100.4°F]). Nurses should assess for respiratory distress, tachycardia, tachypnea, abnormal vital signs, fever, nonblanchable rash, and stiff neck. Included in the assessment should be mouth or stool malodors, upper airway accessory muscle retractions, wheezing, abnormal noises, shrill or weak cry, sore throat, abnormal posturing, bulging, or depressed anterior fontanelle in children. Nurses should assess for vomiting, diarrhea, lethargy, pallor, mottling, cyanosis, capillary refill greater than 2 seconds, skin tenting, petechiae, no tears with crying, or dry mucous membranes. Other concerns include decreased urine output, decreased intake by mouth, extremity swelling, sores in the mouth, redness of the eyes, peeling of the hands or feet, or any subtle change in neurologic behavior or seizures. The child may exhibit changes in sleep patterns, crying, an inability to be consoled, feeding difficulties, or changes in urine or bowel
E
Patricia A. Normandin, Member, Massachusetts ENA Beacon Chapter, is Emergency Department Staff Nurse, Tufts Medical Center and Northeastern University, Boston, MA; Adjunct Nursing Faculty, Brigham & Women's Hospital and Massachusetts General Hospital, Institute of Health Professions, Boston, MA; and Term Lecturer, Site Clinical Instructor, Boston Children's Hospital, Boston, MA. For correspondence, write: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN; E-mail: [email protected] J Emerg Nurs 2015;41:160-1. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.12.008
160
JOURNAL OF EMERGENCY NURSING
movements. It is crucial that all emergency nurses know pediatric growth and development behaviors to ensure prompt identification of real pediatric emergencies. Children with chronic lung conditions such as asthma are at increased risk of rhinoviruses, enterovirus D68, respiratory syncytial virus, and respiratory infections. The child’s age and symptoms, as well as common seasonal illnesses, should be included when considering possible diagnoses. It is important to obtain an accurate immunization history because unimmunized or under-immunized children are vulnerable to infectious disease. A normal temperature or hypothermia does not exclude sepsis in children. Sepsis red flags in children include fever in neonates (b 28 days old), infants younger than 3 months, children with chronic medical conditions, immunocompromised children, and children younger than 2 years with fever of unknown origin. 1–3 Interventions
Pediatric patients who present with potential infectious diseases need to be immediately isolated and appropriate infection control precautions (standard, droplet, contact) and interventions initiated. Nursing care includes continuous monitoring of oxygen saturation, heart rate, respirations, temperature, and intermittent blood pressure. Supportive measures to resolve hypovolemia and electrolyte imbalances should be initiated. Measures to maintain airway and breathing by positioning the child in an upright position of comfort should be instituted if needed, and administration of oxygen via a 100% non-rebreather mask or “blow-by” oxygen should be considered. It might be necessary to suction the nares and mouths of children with secretions, with the understanding that infants are obligatory nose breathers for the first 6 months of life. If capillary refill is greater than 2 seconds, and the child is showing signs of decompensation, immediately initiate a bolus of intravenous or intraosseous isotonic hydration, 20 mL/kg, administer rapidly using the syringe and stopcock method, usually over 5 to 10 minutes. Intravenous bolus interventions should be repeated up to 3 to 4 times to maintain circulation (until capillary refill is less than 2 seconds) by rapidly administering repeat boluses, 20 mL/kg over 5 to 10 minutes using the syringe and stopcock method to stabilize the child. Antipyretics should be administered as
VOLUME 41 • ISSUE 2
March 2015
Normandin/PEDIATRIC UPDATE
TABLE
Common signs and symptoms and possible differential diagnoses 1,2 Sign or symptom
Possible differential diagnoses
Fever
Bacterial meningitis, malaria, otitis media, septic arthritis, sinusitis, pneumonitis, Haemophilus influenzae type B, influenza, urinary tract infections, septicemia, Ebola, mumps, rabies, Lyme disease, herpes simplex viruses Bacterial meningitis, viral meningitis, chicken pox (varicella), coxsackievirus, diphtheria, erythema infectiosum (fifth disease), measles (rubeola), roseola, rubella (German measles), Rocky Mountain spotted fever, mononucleosis, community-acquired methicillin-resistant Staphylococcus aureus, toxic shock syndrome, hand-foot-andmouth disease, group A streptococcus, sexually transmitted diseases, herpes simplex virus Community-acquired methicillin-resistant Staphylococcus aureus, abscess, scalded skin syndrome, cellulitis, group A streptococcus, tetanus Respiratory infection/pneumonia in children, viral or bacterial gastrointestinal infections Rotavirus, gastrointestinal bacterial infections, gastrointestinal viruses, salmonella, Ebola (rare in children), norovirus Viral infection, bacterial infection, parasitic infection, antibiotic-associated diarrhea (Clostridium difficile), gastroenteritis, Escherichia coli, calicivirus, adenovirus Hemolytic uremic syndrome, rotavirus, E coli, shigella, campylobacter, salmonella, other enteropathogens Pneumonia, bronchiolitis, respiratory syncytial virus, upper respiratory infections, enterovirus D68, other enteroviruses, epiglottitis, rhinoviruses, tuberculosis Croup, pneumonia, pneumococcal infections, flu, upper respiratory infections, pertussis (whooping cough) Mononucleosis, flu, viral syndromes, septicemia, hepatitis, poliomyelitis
Rash
Soft-tissue infections Vomiting Vomiting and diarrhea Diarrhea Bloody diarrhea Respiratory distress including rapid breathing Cough Malaise, body aches, fatigue
It should be noted that symptoms overlap in many infectious diseases. A child with chronic infections should undergo a thorough evaluation by his or her pediatrician for undiagnosed underlying conditions such as cystic fibrosis, human immunodeficiency virus, genetic disorders, or malignant disorders.
needed to manage fever (aspirin should never be used because of the association of aspirin, viral infection, and Reye’s syndrome) and antibiotic therapy begun depending on the suspected diagnosis. If bacterial meningitis is suspected, antibiotics should be immediately administered regardless of whether diagnostic testing has been completed. Septic evaluation including blood tests, chest radiographs, and urine, blood, sputum, spinal fluid, and stool cultures should be completed. Preventative Measures and Patient Teaching
We must never forget that proper hand washing, as well as appropriate and thorough cleaning of all equipment after use, is the best way to prevent the spread of infection. The Centers for Disease Control and Prevention (www.cdc.gov) has many free important pediatric teaching tools for pediatric health care providers, parents, and child care providers. Nurses should share with parents and child care
March 2015
VOLUME 41 • ISSUE 2
providers the importance of maintaining their own up-todate immunizations, as well as those of the children. REFERENCES 1. Emergency Nurse Association. Emergency Nursing Pediatric Course Provider Manual. 4th ed., Des Plaines, IL: Emergency Nurse Association; 2014. 2. London ML, Ladewig PW, Ball JW, Bindler RC, Cowen KJ, eds. Maternal & Child Nursing Care. 3rd ed.Upper Saddle River, NJ: Pearson; 2011. 3. Centers for Disease Control and Prevention. Enterovirus D68 in the United States, 2014. http://www.cdc.gov/non-polio-enterovirus/outbreaks/EVD68-outbreaks.html. Accessed November 28, 2014
Submissions to this column are encouraged and may be sent to Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P [email protected] or Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN [email protected]
WWW.JENONLINE.ORG
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