Peds-- Hematology & Immunology

Thalassemia

A blood disorder involving less than normal amounts of an oxygen-carrying protein. Thalassemia is an inherited blood disorder characterized by less oxygen-carrying protein (hemoglobin) and fewer red blood cells in the body than normal. Symptoms include fatigue, weakness, paleness, and slow growth. Mild forms may not need treatment. Severe forms may require blood transfusions or a donor stem-cell transplant. Thalassemia major is the most severe form of beta thalassemia. It develops when beta globin genes are missing. The symptoms of thalassemia major generally appear before a child's second birthday. The severe anemia related to this condition can be life-threatening. Thalassemia is a group of hereditary hemolytic disorders caused by defective hemoglobin synthesis. It is more common in some populations, such as those from Mediterranean, African, or Asian descent. Thalassemia major, also known as Cooley anemia, is the homozygous form that results in severe anemia, requiring regular blood transfusions and management of iron overload. Early treatment prevents complications, and stem cell transplant can be curative. TEACH: Regular blood transfusions can prevent skeletal abnormalities. Low hemoglobin levels in thalassemia lead to marrow expansion which causes various skeletal deformities due to invasion of bone and impairment of bone growth. Maintaining adequate hemoglobin levels via transfusion can prevent this effect. Treatments to prevent excessively high iron levels will be needed. To minimize the development of hemosiderosis and hemochromatosis, caused by decreased hemoglobin synthesis and hemolysis of transfused blood in thalassemia, deferoxamine, an iron-chelating agent, is given. A stem cell transplant can be used as part of the treatment plan. Clients who are eligible for stem cell transplant have about 90% likelihood of being cured; this procedure is recommended rather than lifelong medical therapy. NOT: Transfusions begin once the child reaches two years of age. Transfusions are started as soon as clinically indicated, with no minimum age requirement, in order to prevent developmental complications such as heart failure. The child should grow out of this condition by young adulthood. Thalassemia is a congenital condition the client will not "grow out of." A cure is possible by measures such as stem cell transplant.

Hemophilia

A disorder in which blood doesn't clot normally. When blood can't clot properly, excessive bleeding (external and internal) occurs after any injury or damage. Symptoms include many large or deep bruises, joint pain and swelling, unexplained bleeding, and blood in urine or stool. Treatment includes injections of a clotting factor or plasma. Hemophilia is a bleeding disorder caused by a congenital deficiency, dysfunction, or absence of certain coagulation proteins or factors. The two most common factor deficiencies are in factor VIII and factor IX. Diagnosis is made from a history of bleeding episodes, and specific testing of assays for factors VIII and IX are done to confirm the diagnosis. Diagnosis: Factor assays Testing specific to hemophilia includes factor VIII and factor IX assays. NOT: Hemoglobin level Hemoglobin level is not specific to hemopholia; an injured client may present with a low hemoglobin level if severe bleeding has occurred. Prothrombin time Prothrombin time is normal in clients with hemophilia. Platelet count The platelet count is normal in hemophilia; the issue is with deficiency of factors VIII and IX. Desmopressin, an antifibrinolytic, works by increasing the release of factor VIII (von Willebrand factor). Factor VIII attaches platelets to damaged areas of blood vessels via the glycoprotein Ib platelet receptor. Desmopressin promotes the release of prostaglandin I2 and plasminogen activator, in addition to factor VIII. The overall result is increased clot formation to inhibit bleeding, which is useful for conditions such as hemophilia. Hemophilia is a bleeding disorder caused by a congenital deficiency, dysfunction, or absence of certain coagulation proteins or factors. The two most common factor deficiencies are in factors VIII and IX. Because of the high risk of uncontrolled bleeding, clients should take precautions to lower the risk of injury. Certain activities, such as the strengthening of the bones and muscles, can diminish the bleeding that occurs with an injury. One of the most common problems associated with hemophilia is joint degeneration due to chronic bleeding within the joints. TEACH to manage disease: Use of physical therapy Physical therapy is an important intervention for clients with hemophilia as it strengthens muscles and joints which limits bleeding associated with injury. NOT: Avoidance of all contact and non-contact sports Protective equipment should be used for physical activities, and those with severe hemophilia should only participate in non-contact sports such as tennis, swimming, and jogging due to the risk of uncontrolled bleeding. Avoidance of bristled toothbrushes Soft-bristled toothbrushes can be placed in warm water to increase softness and decrease bleeding during oral care. Adherence to blood-thinning medication Hemophilia is a disease in which ineffective clotting is a concern; blood thinners are contraindicated

Hemolytic reaction to blood transfusion

A hemolytic reaction occurs with a Rh or ABO incompatibility. Acute hemolytic transfusion reactions are commonly caused by an ABO incompatibility and occur during the transfusion or within 24 hours after. The client may report burning at the IV site, chills, and pain in the back and flank. Fever may be noted. Incompatible RBCs with antigens from the wrong blood group are attacked and destroyed by antibodies in the client's plasma, leading to widespread hemolysis. These antibodies activate complement, and tissue factor is released by RBC debris, triggering the clotting cascade. Disseminated intravascular coagulation (DIC) results, causing shock, acute renal failure, and even death. To prevent these reactions, two nurses must carefully check the client's name, date of birth, blood type, and blood band number, and match these with the blood type and blood band number on the unit of blood. Reaction: A-negative blood to a B-negative client A hemolytic reaction would occur with A-negative blood given to a B-negative patient due to an ABO incompatibility even though they are both Rh negative. OK: A-negative blood to an AB-negative client AB clients can receive wither A or B blood types, as long as there is an Rh compatibility. O-negative blood to a B-negative client O-negative blood is the universal donor because it does not have A or B properties, and A and B blood types do not have O antibodies. B-negative blood to a B-positive client The Rh factor is the presence of antigens (proteins) on the cell, which may cause a reaction if the client is sensitized to the antigen. Rh-negative blood can donate to Rh-positive blood if it is the same type because there are no antigens.

Rocky Mountain Spotted Fever (RMSF)

An infectious disease with a characteristic rash, often transmitted by the bite of a tick. Rocky Mountain spotted fever is a potentially fatal disease that's usually caused by the bite of a tick infected with rickettsia group bacteria. Symptoms include fever, headache, and muscle aches. A rash may be present, frequently with blackened or crusted skin at the site of a tick bite. Spotted fever responds well to prompt treatment with antibiotics. Rocky Mountain spotted fever, the most common rickettsial disease in the United States, is a bacterial infection transmitted by a tick. It can be a life-threatening illness if undiagnosed or untreated. The disease begins with a fever, usually within a few days after a tick bite. Along with a headache and myalgia, a maculopapular rash develops two to six days after the onset of the fever. The rash first appears in the wrists and ankles, then spreads centripetally to the trunk. Anticipated with assessment: Rash that started on the wrists and ankles and has spread to the trunk A rash develops on the wrists and ankles and then spreads to the trunk two to six days after the onset of fever. Three-day headache unrelieved by over-the-counter medication A headache usually develops two to six days after the onset of fever with Rocky Mountain spotted fever. NOT: Observation of arching the back and client reports of jaw muscle spasms Spasms of the jaw and arching of the back are signs of tetanus. Mild temperature elevation of 100 °F (37.8 °C) or less Symptoms of Rocky Mountain spotted fever include a headache and high fever. Inability to flex the neck due to nuchal rigidity, which has been present for 48 hours Stiff neck is a sign associated with meningitis.

Aspirin: Reye's Syndrome

Aspirin and other salicylates are contraindicated for use in children who have symptoms related to viral illnesses, as both viruses and aspirin use have been noted as triggers for Reye syndrome, a rare but life-threatening condition. The condition involves liver damage and progressive neurologic deficits, which may worsen to a comatose state. Those who survive may have residual neurological damage.

HIV Confidentiality

Clients and legal guardians have a right to keep medical information private and do not have to report health conditions. Health care workers can stress that clients should inform sexual partners and educate clients on strategies to prevent the spread of HIV, but they cannot inform anyone of a client's condition without express consent from the client. This type of information is best provided by the client. In some states or cities, the initial diagnosing practitioner is required to inform the Department of Health about any known contacts or partners, and the Department of Health determines whether those individuals need to be informed with or without the client's consent. Other locales have laws that require partners and contacts to be notified by the client with HIV, or the client risks legal action. Health care providers are required to report cases of HIV infection to the Department of Health, and in many states, laboratories report HIV nucleic acid tests (viral load tests), CD4 lymphocyte tests, and drug resistance and subtype tests to the State Department of Health. This reporting helps to monitor the HIV epidemic accurately and to create programs for HIV prevention to serve affected people and communities. Strict confidentiality laws protect all reported information. How to respond to parents who don't want to tell the school of their child with HIV: "It is your right to maintain confidentiality." Clients and their guardians have the right to keep medical information, including HIV status, private. No rule or law states that a client must inform any particular person or body of people of a health condition, including HIV. NOT: "The health care provider is required to notify the school." Health care professionals cannot inform anyone else of a client's health condition, as this is against the Health Insurance Portability and Accountability Act. "Your child will have to wear a face mask at school." The child will not have to wear a face mask at school. Furthermore, this would not be the best way to prevent the spread of HIV, as HIV is not an airborne disease. "You are required to inform the school." Clients are not required to divulge medical conditions, including HIV, to anyone.

contact precautions for these diseases

Contact precautions prevent the spread of infectious diseases transmitted by contact with body substances containing the infectious agent or items contaminated with the body substances containing the infectious agent. Standard precautions protects the nurse from blood-borne infections and all clients are cared for with these measures. Contact precautions: Hepatitis A virus Hepatitis A in a diapered or incontinent client requires the use of contact precautions for the full duration of illness. Scabies Scabies requires the use of contact precautions until 24 hours after initiation of effective therapy. Rotavirus Rotavirus infection in a diapered or incontinent client requires the use of contact precautions for the full duration of illness. NOT: Hepatitis B virus Hepatitis B requires only standard precautions, not contact. Human Immunodeficiency virus Human Immunodeficiency virus requires only standard precautions, not contact.

Coxsackievirus A16

Coxsackievirus A16 is a virus that causes a rash on the hands and feet as well as ulcerations in the mouth and throat. These ulcers make swallowing painful and difficult, causing decreased oral intake, particularly solids. If the child refuses liquids as well, dehydration can result. Notify HCP: No urine output in six hours. Lack of urine output for this length of time indicates dehydration, likely caused by decreased oral intake due to painful mouth ulcers. DON'T: Difficulty eating solid foods is noted. Painful mouth ulcers which make it difficult to swallow. Erythematous rash is noted in diaper area. This finding is likely due to diaper dermatitis and is not a concerning finding. Small ulcerations appear in the oral cavity. Oral ulcers are a normal finding. The virus causes vesicles on the palms of the hands, soles of the feet and oral mucous membranes. The oral vesicles erupt, leaving shallow ulcers.

Care for HIV positive baby

Daily care of an infant with HIV may be very similar to the care of a healthy infant. Particular attention must be paid to preventing infection, however, and parents must be instructed how to be vigilant in protecting the child from possible illness. Family members can co-exist with the HIV-positive baby without wearing protective clothing. Feeding, bathing, and diapering is done in the same manner for an infant with HIV, as one without HIV. Routine immunizations are increasingly important in the child with HIV, and should be completed on time, unless the child is actively ill. TEACH: "Be sure to have the baby immunized as scheduled." Immunization against common childhood diseases, including pneumococcal and influenza vaccines, should be given to infants and children with HIV. NOT: "Clean feeding bottles with water and isopropyl alcohol." Bottles of infants with HIV should be cleaned with soap and hot water. After cleaning, bottles may be sterilized by immersing in boiling water. Although bleach and/or alcohol solutions are effective at killing HIV virus, this step is not necessary if the bottles will be used only by the infant with HIV. "Anyone changing the baby's diapers must wear gloves." Gloves are not necessary for parents or those caring only the child with HIV, as HIV is not spread through feces or urine unless there is blood present. Health care workers should practice universal precautions, which includes wearing gloves to change infant or adult diapers. "Avoid exposing healthy children to your sick baby." HIV is not spread through casual contact, such as playing or eating together. It is not necessary to restrict healthy visitors from the infant with HIV. Due to the infants' compromised immune system, however, the baby with HIV should not be exposed to sick children or adults. As it is not possible to determine the illness status of large crowds of people, the infant with HIV should not be taken among large crowds of people. The nurse uses appropriate transmission-based precautions based on risk for infection. The client who is HIV-positive requires no additional precautions compared to other clients, because universal precautions, which are applied to all clients, reduce the risk for exposure to all blood-borne pathogens. Precautions: Universal precautions Universal precautions treat all blood and high-risk body fluids as if they were infected with HIV or other blood-borne pathogens. NOT: Blood and body fluid precautions There is no such designation as blood and body fluid precautions. Contact transmission-based precautions Contact precautions are reserved for organisms transmitted by direct or indirect contact with the patient or the patient's environment, and HIV is a blood-borne pathogen. If there is the risk for accidental exposure to blood, such as a procedure that could result in spraying of blood and fluids, the nurse would institute additional precautions, such as gown, gloves, and goggles. Reverse transmission-based precautions Simply being HIV-positive requires no special precautions. The only reason for protective transmission-based precautions would be if the client was deemed especially immunocompromised. Clients who are immunocompromised due to HIV should take caution in regards to "live" (attenuated) vaccines due to the risk of severe illness and death. When the client is not severely immunocompromised, because of the increased risk from complications associated with varicella and measles, those who test positive for HIV should still receive these live vaccines. Re-schedule: Yellow fever Yellow fever is a live (attenuated) vaccine and is contraindicated in the client immunocompromised with HIV. OK: Varicella Varicella is still recommended except in cases of severe compromise. Measles, Mumps, Rubella (MMR) MMR is still recommended except in cases of severe compromise. Inactivated Polio Virus (IPV) Oral polio is a live virus vaccine and is contraindicated in HIV clients, but it is no longer used in the US; inactivated polio is acceptable for the HIV-positive client. Diptheria, Tetanus, Pertussis (DTaP) Tetanus is an inactivated vaccine and can safely be administered to clients who are immunocompromised from HIV.

flu vaccine

Educating parents about the importance of vaccinating against influenza is important for health promotion and illness prevention. Vaccine education can help to dispel myths and outdated information. TRUE: Early fall is the ideal season for the influenza vaccine. Receiving the influenza vaccine in early fall provides the best protection during the peak season. Vaccinating anytime in the fall is preferred over failure to obtain a vaccination. Peak season is when the highest number of influenza cases are expected to occur, and, according to the CDC, is November through March. FALSE: The influenza vaccine is required every other year. Per the CDC, the influenza vaccine is required annually. Children with an egg allergy may not receive influenza vaccine. Children with a severe egg allergy may need further evaluation by their healthcare provider and risk versus benefit determined prior to vaccination. Most egg allergies do not present a contraindication to being vaccinated against influenza. Children must be one year of age to receive the influenza vaccine. Children after the age of 6 months should receive the influenza vaccine as they are in a higher risk category to suffer from influenza complications.

febrile seizures

Febrile seizures are common, affecting roughly 3% of children. This type of seizure is benign and self-limiting, and does not affect cognitive function, nor require treatment with anti-epileptic drugs. Most febrile seizures occur while the temperature is spiking, so antipyretics are given. If bacterial infection is the cause of fever, antibiotics are prescribed. Tepid sponge baths are not recommended, as they are uncomfortable for child, ineffective in lowering fever significantly, and tend to cause shivering which increases body temperature, thus increasing chance of febrile seizure. TEACH: Reassurance that febrile seizures are benign Febrile seizures are common, benign, self-limiting, and cause no long term sequelae. NOT: Instructions for hourly tepid sponge Tepid water baths are uncomfortable for child, ineffective in lowering the fever, and tend to cause shivering which increases body temperature, thus increasing chance of febrile seizure Administration of antipyretics around the clock Antipyretics are given as needed only; attempts to lower body temp do not prevent a febrile seizure. Administration of anti-epileptic medications Anti-epileptic drugs are not indicated for febrile seizures.

Fifth disease

Fifth disease is a mild viral illness caused by parvovirus B19 common in children ages five to fifteen years. Aplastic crisis is associated with this viral infection in clients with conditions affecting red blood cell production, such as sickle cell disease, thalassemia, or hereditary spherocytosis. Patients with aplastic crisis experience sudden severe anemia, which can lead to heart failure and other complications. Manifestations are the same as for any acute-onset anemia, including pallor, weakness, and lethargy, with compensatory responses of tachypnea and tachycardia. Immediately report if school aged client also has thalassemia major: Increase in heart rate from 90 to 125 beats/min. The increase in heart rate is a sign of compensation for decreased tissue perfusion, which could indicate worsening anemia. The client is at high risk for aplastic crisis, so the nurse should be alert to signs of worsening anemia. NOT: Maculopapular rash on torso and cheeks A rash on the cheeks is the hallmark of fifth disease and sometime referred to as a "slapped cheek" appearance. This normal finding does not require reporting to the health care provider. Restlessness and difficulty staying in bed Restlessness or increased energy may be a positive sign and an indicator of recovery from the viral illness. If the child were to exhibit lethargy and weakness, this is a sign of aplastic crisis and should be immediately investigated. Increase in systolic blood pressure from 90 to 110 mmHg An increase in blood pressure is not associated with a common complication of thalassemia or fifth disease. The nurse should conduct further assessment based on this finding but it does not warrant immediate notification of the health care provider.

DTaP

Following immunization with DTaP, slight fever and pain at the injection site are possible. The nurse should instruct the parents to give acetaminophen or ibuprofen. Other common problems include fussiness, poor appetite, and vomiting within three days of the vaccination. The parent should report more moderate or severe complications to the healthcare provider. These include seizures, non-stop crying, fever greater than 105 °F (40.6 °C), or signs of allergic reaction, as these may indicate the child should not receive further DTaP immunizations. Requires additional teaching: "It is normal for the infant to develop a rash on his belly within the next few days." A rash is a sign of an allergic reaction and the provider should be notified. NOT: "I can administer acetaminophen or ibuprofen to help with anticipated fussiness." Due to the anticipated fever and discomfort at the site of injection, it is acceptable to administer aspirin free pain reliever, such as ibuprofen or acetaminophen in appropriate dosages. "The infant will likely show signs of discomfort in the affected leg when manipulated." Soreness or tenderness at the site of injection is a common problem. "If the infant develops a fever greater than 105 °F (40.6 °C), I should contact the pediatrician." Fever is a common side effect of the DTaP vaccine; however, if a child develops a high fever of 105 °F (40.6 °C) or higher, the provider should be notified. DTaP vaccination provides immunization against diptheria, tetanus (lockjaw), and pertussis (whooping cough). Children who receive the recommended series of five vaccinations (two months, four months, six months, 15-18 months, and four to six years) have protection throughout childhood. Infants who are not immune to pertussis (whooping cough) have a high risk of mortality if exposed. Healthy adults and older children are more likely to have a full recovery without complications. TRUE: "Infants receive this immunization because if they contract pertussis, the mortality rate is high." Infant mortality is high for infants who are exposed to pertussis if not immune. FALSE: "This immunization is given earlier due to the increased risk of an allergic reaction as the infant grows." The risk for an allergic reaction does not change regardless of infant age. "This is the only dose of this vaccination your infant will receive until beginning kindergarten." The vaccination series for DTaP includes five doses: two months, four months, six months, 15-18 months, and four to six years of age. "It is important for the infant to recieve the tetanus immunization series before crawling." Crawling is not a factor to consider for immunization.

Hemolytic Uremic Syndrome (HUS)

Hemolytic uremic syndrome (HUS) is an acute kidney disease that primarily occurs in children ages six months to five years of age. HUS is characterized by hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. The etiology of HUS is likely associated with bacterial toxins, chemicals, and viruses. Symptoms include vomiting, irritability, lethargy, pallor, hemorrhagic manifestations, jaundice, seizures, coma, and possibly signs of acute heart failure. Hemolytic uremic syndrome (HUS) is a condition that can occur when the small blood vessels in your kidneys become damaged and inflamed. This damage can cause clots to form in the vessels. The clots clog the filtering system in the kidneys and lead to kidney failure, which could be life-threatening. Findings to be expected: Petechiae Petechiae occurs due to platelet aggregation in damaged blood vessels or as a result of the damage and removal of platelets. Yellow skin Jaundice occurs, which manifests with yellowing of the skin, due to the excessive filtering of damaged red blood cells by the liver. Bruising Bruising occurs due to thrombocytopenia. 20% Bloody stool Bloody stool may occur due to damaged or removed platelets. NOT: Polyuria Polyuria does not occur with HUS. Oliguria or anuria may be seen instead due to compromised kidney function. Hemolytic uremic syndrome (HUS) results from the abnormal destruction of red blood cells, which start to damage the kidneys. HUS is characterized by hemolytic anemia, thrombocytopenia, and acute renal injury. Most cases of HUS develop in children after two to fourteen days of often bloody diarrhea due to infection with Escherichia coli. Bloody diarrhea and fever develop, followed by symptoms of hemolytic anemia, such as fatigue, and low urine output due to acute renal injury. Other signs and symptoms include hematuria, hypertension, edema, abdominal pain, and encephalopathy. Anticipated findings: Bloody stool Bloody diarrhea is a common symptom of HUS. Decreased urinary output Decreased urinary output is a common symptom of HUS, typically after several days of diarrhea, which may be bloody. Fever Fever often develops along with bloody diarrhea with HUS NOT: Dyspnea Dyspnea is not a symptom associated with HUS. Generalized rash There is no rash associated with HUS.

heparin administration

Heparin is an anticoagulant made from the intestines or lungs of pigs. In the past, heparin was commonly used to maintain IV patency, but best practice now is to use 0.9% sodium chloride flushes for this purpose. Heparin is also used for the prevention and treatment of deep vein thrombosis (DVT). Dosage is based upon weight in kilograms, so ascertaining that the unit of measurement used is kilograms, not pounds, is essential in preventing a medication error, especially in the pediatric population. Weight should be taken immediately before administration due to weight fluctuations with growth and other conditions. Most IMPORTANT assessment before initiating: Weight The client's weight should be obtained, as heparin, an anticoagulant, dosing is based upon weight. Children may have weight changes as they grow; therefore it is important that a weight is obtained before each administration.

Hepatitis B vaccine

Hepatitis B is a disease that affects the liver and can lead to mild or severe illness. Vaccination consists of a series of three to four injections over a six- to twelve-month period. The first dose of the hepatitis B vaccine should be given at birth and the second dose at one month. Some providers delay the first dose until the first visit after hospital discharge, typically at one to two weeks of age. The second dose is given at one to two months of age and the third dose at one year of age. GIVE at 2 weeks visit: Hepatitis B If not administered while in the hospital, the first dose of the hepatitis B vaccine is adminstered at the two-week visit. Other vaccines: Polio The first dose of the polio vaccine is administered at two months of age. Diptheria, tetanus, pertussis (DTaP) The first dose of the DTaP vaccine is adminstered at two months of age. Measles, mumps, rubella (MMR) The first dose of the MMR vaccine is administered between 12 and 15 months of age.

Neonatal sepsis

Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days old. Early-onset sepsis is seen in the first week of life. Late onset sepsis occurs after 1 week through 3 months of age. Neonatal sepsis is a medical emergency and the nurse must be able to recognize the signs immediately, monitor the infant's vital signs and be prepared to assist in the workup and treatment. Obtaining cultures takes priority, as the first dose of antibiotics must be administered as soon as possible, but not before cultures are obtained, as this will interfere with the culture results. The infant's immunization status is not relevant because the pathogens that cause neonatal sepsis are often not pathogens for which children are immunized except for streptococcus pneumoniae, and those immunizations are not given until age 2 months. Traumatic brain injury to the infant can also cause vomiting, sleepiness and seizures and can be caused by a fall or by shaking. The parents of a 1-month-old infant client present to the emergency department stating that the infant has vomited three times in two hours, is lethargic and began shaking uncontrollably. After obtaining a full set of vital signs, which does the nurse include in the plan of care? CORRECT: Ask the parents about any history of prolonged crying. Asking about prolonged crying is to rule out atraumatic head injury (or Shaken Baby Syndrome); the clinical findings are similar to neonatal sepsis. Hold the infant for a lumbar puncture. A lumbar puncture is done to diagnose neonatal sepsis, specifically meningitis. Obtain blood and urine cultures. Cultures are lab tests done to diagnose neonatal sepsis and the causative organism. NOT: Administer IV antibiotics immediately. Antibiotics can be given before all lab results are available, but should not be given until all cultures and specimens are obtained to ensure identification of the correct organism and thus appropriate and effective antibiotic. Assess immunization status. No immunizations except Hepatitis B are given until age 2 months. Neonatal sepsis is a medical emergency, and the nurse must be able to recognize the signs, as the morbidity and mortality rate can be as high as 30 to 50% respectively. Signs of neonatal sepsis may be vague and non-specific, including poor feeding, sleepiness, vomiting, early jaundice and temperature instability. Any of these findings must be reported to the health care provider immediately. A 4-day-old neonatal client is diagnosed with group B streptococcal sepsis. The nurse is concerned about which finding? CORRECT: Temperature 96.6° F (35.9° C) Temperature instability (i.e., hypo- or hyperthermia) occurs with neonatal sepsis and meningitis, either in response to pyrogens secreted by the bacterial organisms or from sympathetic nervous system instability. WRONG: Apnea lasting 15 seconds. Apnea up to 20 seconds is physiologically normal in neonates. Maculopapular facial rash This indicates erythema toxicum neonatorum, a normal finding in neonates and is not indicative of illness. Arterial pH 7.46 Normal arterial pH is 7.35-7.45. This is not a concerning pH. Sepsis is a systemic response, usually secondary to an infection, that can be dangerous and life threatening for infants. The infant must be monitored closely for signs of improvement as they are unable to verbalize that they are feeling better. The nurse must look at their behavior and overall health for signs that treatment is working and the infection is resolving. Indication of improvement: Healthy appetite. A healthy appetite would indicate that the infant is recovering and feeling better. Playful demeanor. An infant that is playful is a sign that they are feeling better and would indicate treatement of sepsis is working. Fontanel appears normal. A fontanelle that is swollen or sunken in is a symptom that an infant is poor health. A sunken in fontanelle often indicates dehydration while swelling indicates fluid in the brain. NOT: Parents report improvement. It is always important for the nurse to listen to parents and their observations of this child. A parent reporting that their infant is improving would not, however, indicate that the sepsis has improved and would require further assessment from the nurse. Transient tachypnea. There are many reasons why an infant could have labored breathing or fast breathing. Altered breathing can be a result of sepsis is a common presenting symptom, but could be from something unrelated. It would be important to assess this infant further to see why they are having breathing difficulties.

immunity types

Immunity develops when the body is exposed to microorganisms and the immune system develops antibodies to destroy or disable the microorganisms. Immunity can be natural or artificial and active or passive. Artificially acquired, active immunity results from the use of ingested or injected vaccines, medically altered substances, which stimulate the immune system to produce antibodies. Naturally acquired, active immunity occurs when antibodies develop after natural exposure to a pathogen. Naturally acquired passive immunity occurs when antibodies are directly received through the placenta or breast milk. In passive immunity, the antibodies are given, not developed by that client. Artificially acquired passive immunity results when antibodies are artificially delivered to the body, such as via blood transfusions. immunity type for MMR vaccine: Artificial Artificial immunity occurs when an individual ingests or is injected with a medically altered substance, such as a vaccination, that triggers the immune system to produce antibodies. Active Active immunity develops after the body has been exposed to an antigen, which stimulates the body to produce antibodies. NOT: Passive Passive immunity results from the transfer of antibodies from one person to another. Natural Natural immunity occurs when an individual is exposed to a live pathogen and develops disease, triggering the body's primary immune response and development of antibodies. Inactive Inactive immunity is not a correct term. The correct terminology is passive.

HIV testing for newborns

In babies born to HIV-positive mothers, the CDC recommends performing a series of virologic HIV tests at different intervals. Antibody testing alone in a newborn is not accurate because of transplacental transfer of maternal antibodies to the infant in utero. The infant must have two negative virologic tests to be deemed HIV-negative. Mom is relieved baby is negative, how should nurse respond?: "That is great news. Have you arranged for the second test yet?" The CDC recommends testing between the ages of two to three weeks, a second test at one to two months, and a third at four to six months. The nurse should ensure the mother is aware of, and has arranged for, the second test. NOT: "Tell me more about your feelings about having HIV and a new baby." The client is not expressing feelings related to being HIV positive. While therapeutic communication allows for exploration of feelings, this exploration needs to be appropriately placed. In this case, the focus is on testing the infant for HIV and not on the mother's feelings about having HIV and a new baby. "It must be a relief knowing the antiviral medication worked." It is not known if the child is virus free until all tests have been completed. "That is good to hear but remember that you can still pass on the virus." The mother can transmit the virus via breast feeding and this could be a topic for reinforced teaching but given the client's comment, the priority for the nurse is to ensure the mother knows additional testing is required.

Von Willebrand Disease

In von Willebrand disease, the body has a deficiency of von Willebrand factor (vWF). vWF helps release factor VIII, and in its absence, factor VIII degrades, causing a prolonged aPTT and decreased platelet adhesion. The client has platelets, but they do not adhere together to form clots. Von Willebrand disease is the most common hereditary coagulation abnormality, but it can also be acquired. Supports diagnosis: Activated partial thromboplastin time (aPTT) 70 seconds aPTT is prolonged (more than 40 seconds) with von Willebrand disease. DOESN'T support: Prothrombin time (PT) 12.5 seconds A prolonged PT (more than 12.5 seconds) occurs with a vitamin K deficiency or coumadin therapy but is normal with von Willebrand's Platelets 150 K/mL Platelet values are normal with von Willebrand disease, not decreased, but there is decreased platelet adhesion. International normalized ratio (INR) 3.5 seconds An increased INR (more than three seconds) occurs with a vitamin K deficiency or coumadin therapy. Activated partial thromboplastin time (aPTT) 70 seconds aPTT is prolonged (more than 40 seconds) with von Willebrand disease. 1 Von Willenrand disease is a disorder in which the blood does not properly clot due to low levels or improper functioning of von Willebrand factor. Most people with the disease are born with it, but a spontaneous mutation can rarely occur in individuals without a family history of the disease. Signs and symptoms include frequent nosebleeds or nosebleeds that are hard to stop, easy bruising, heavy menstrual bleeding, excessive bleeding after dental work, and other unusual bleeding occurrences. Testing is aimed at determining the level of clotting proteins present and whether or not they are functioning appropriately. A combination of testing is done to confirm the diagnosis such as a complete blood count, activated partial thromboplastin time (aPTT), prothrombin time (PT), and fibrinogen testing. Other specific testing is done to determine which bleeding disorder is present and may include factor VIII clotting activity, von Willebrand factor antigen, ristocetin cofactor activity, von Willebrand factor multimers, and platelet aggregation testing. TEACH: Tests are done to assess clotting proteins. Testing is aimed at determining the amount of and ability of clotting proteins and to assess whether the blood is clotting properly. Testing will likely need to be repeated. Testing specifically for VWD is often repeated several times to get an accurate diagnosis. Factors such as stress, pregnancy, and infections can alter the level of clotting factors. DON'T: Testing is performed to assess for leukopenia. Testing is performed to collect information on the number of clotting proteins present, not for leukopenia (low white blood cell count). The client cannot eat or drink 12 hours before testing. There is no restriction on eating or drinking before laboratory testing that is done to assess for clotting proteins. It is not unusual for hemoglobin levels to be low. Hemoglobin levels are not usually low. Levels may be low if the client has experienced heavy bleeding, but this is not a typical finding. Von Willebrand disease is a hereditary coagulation disorder caused by a deficiency of von Willebrand factor, which is required for platelet adhesion. It is the mildest form of inherited coagulation disorders, but it can still lead to problematic blood loss, particularly from epistaxis and menorrhagia. For menorrhagia, factor replacement or desmopressin to increase platelet adhesion can lessen the blood loss, based on severity. Interventions for adolescent with VWD experiencing menorrhagia: Discuss the benefits of prophylactic factor infusions on the first day of the cycle. When heavy bleeding occurs, the use of factor infusions on the first day of the menstrual cycle can help reduce blood loss. Teach the client methods to prevent leaking accidents. An adolescent client is often embarrassed by the realities of menstruation and should be assisted in preventing leakage that could compound this embarrassment. Assess the client's recent hemoglobin levels for changes. The nurse uses any recent changes, or lack of change, in the client's hemoglobin level to help determine the urgency of action required. NOT: Discuss the client's reported concerns with the client's parents. The nurse should not share information with the client's parents unless the client has requested this be done, as this breach of confidentiality could damage the therapeutic relationship. Encourage the client to accept this as an expected part of the condition. Excessive blood loss can lead to iron deficiency and other problems, so the client should not be advised to accept it when intervention may be warranted.

infectious mononucleosis (mono)

Infectious mononucleosis is usually linked to the Epstein-Barr virus. Symptoms include malaise, puffy eyes, loss of appetite, chills, fever, sore throat, cervical adenopathy, splenomegaly, macular eruption, tonsillitis, and palatine petechiae. Heterophile antibody tests, such as the Paul-Bunnell or Monospot tests, respond to immunoglobulin M, which is present in the first two weeks and can be present for up to a year. The Monospot test is preferred over the Paul-Bunnell test because it detects agglutinins at lower levels, aiding in a faster diagnosis. The Monotest is done by collecting blood from the client and placing it on special paper. If the blood forms fragments or clumps, the test is positive. Confirm diagnosis: The spot test The spot test (Monospot) is used to confirm mononucleosis because it is rapid, sensitive, inexpensive, and easy to perform. Mononucleosis is usually linked to the Epstein-Barr virus (EBV). It causes severe fatigue and malaise. Swollen tonsils and lymph nodes, stomachache, and flu-like symptoms are generally present. Epstein-Barr virus antibody test is used to confirm the diagnosis if the heterophile antibody test is negative and the client has symptoms of mononucleosis. LAB findings: Lymphocytes 5.2 K/uL A lymphocyte count greater than 50% or an absolute count of more than 4.5 K/uL is consistent with mononucleosis. Positive Epstein-Barr virus antibody test An individual with mononucleosis has a positive Epstein-Barr virus antibody test. Negative heterophile antibody test The heterophile test often has a false negative result even in the presence of mononucleosis. WBC 15.9 billion cells/L WBC has a modest elevation and peaks between 10 and 20 during the second or third week of illness. NOT: RBC 3.2 milion cells/mcL Anemia may be a cause for fatigue but is not indication for diagnosis of mononucleosis.

iron deficiency anemia

Iron deficiency anemia is often caused by chronic blood loss from minor gastrointestinal bleeding which can occur with colon cancer. Over time, the demands for iron exceed intake. Manifestations of iron deficiency anemia include fatigue, pallor, fissures at the corners of the mouth, and reduced exercise tolerance. A client comes to the clinic with a recent diagnosis of anemia due to iron deficiency and colon cancer. The nurse educates the client that the anemia is most likely caused by which of the following? CORRECT: Chronic blood loss Chronic blood loss diminishes iron and blood supply, causing iron deficiency anemia. WRONG: An autoimmune response An autoimmune response is associated with autoimmune hemolytic anemias, not iron deficiency anemia. Sickle-shaped red blood cells Sickle-shaped red blood cells are associated with sickle-cell anemia, not iron deficiency anemia. Inadequate B12 intake Vitamin B12 deficiency is associated with vitamin B12 deficiency anemia, not iron deficiency anemia.

iron deficiency anemia

Iron deficiency anemia is often caused by chronic blood loss or insufficient iron intake. Manifestations of iron deficiency anemia include fatigue, pallor, fissures at the corners of the mouth, and reduced exercise tolerance. Clients with iron deficiency anemia and their parents should be educated on proper consumption of iron supplements at home to ensure maximum absorption. Iron supplements should be given between meals, when there is the most free hydrochloric acid. The acidity of the gastrointestinal tract allows for better absorption of iron. Consuming citrus foods and vitamin C helps promote absorption as well. Requires additional teaching: "I will give the iron supplement with my child's yogurt snack." Dairy products inhibit the absorption of iron and therefore should not be consumed with iron supplements. OK: "I will give the liquid supplement through a straw." Liquid iron can stain the teeth; therefore it should be taken with a straw or via a dropper. "I expect to see greenish-black stools." Iron supplementation causes black, greenish stools due to unabsorbed iron. "I will let my child drink orange juice after taking iron." Citrus foods contain vitamin C, which helps the body absorb iron; drinking orange juice after taking an iron supplement is appropriate.

Kawasaki disease

Kawasaki disease involves idiopathic acute systemic vasculitis. Children younger than five years of age account for 75% of all cases. The disease is self-limiting, but treatment is needed, as severe cardiac complications can result. Without treatment, 20% to 25% of children develop coronary artery dilation or an aneurysm. Treatment is done with IVIG therapy and salicylates. Full recovery is likely with treatment, though in rare cases, some children may experience residual cardiac effects. Symptoms of Kawasaki disease include arthritis, edema, redness of the palms and soles, conjunctival inflammation, mucous membrane changes, rash, irritability, fever, and cervical lymphadenopathy. Kawasaki disease (KD), also known as Kawasaki syndrome or mucocutaneous lymph node syndrome, is the most common cause of acquired heart disease in children in developed countries. KD affects children and a smaller percentage of teens, creating inflammation in the blood vessels, particularly the coronary arteries. A condition that causes inflammation in the walls of some blood vessels in the body. It's most common in infants and young children. Early stages include a rash and fever. Symptoms include high fever and peeling skin. In late stages, there may be inflammation of medium size blood vessels (vasculitis). It also affects lymph nodes, skin, and mucous membranes, such as inside the mouth. Kawasaki disease is usually treatable. Initial treatments include aspirin and intravenous immunoglobulin therapy given in a medical facility. Immunoglobulin (IVIG) is part of your blood's plasma. It has antibodies in it to fight germs or disease. When people donate blood, this part can be separated out. Then it can be given to you through a vein in your arm, or IV. If you get IVIg, it can help strengthen your immune system so you can fight infections and stay healthy. A toddler-age client receives intravenous immunoglobulin (IVIG) therapy for Kawasaki disease. The nurse educates the parent about the disease and knows that teaching is understood when the parent makes which statement? Understands: "My child may have stiff joints in the morning." Kawasaki disease can cause temporary arthritis due to inflammation, and children may feel stiff in the mornings, after naps, and in cold weather. Requires further teaching: "I will make sure my child receives all immunizations this year." Immunizations should be suspended for the 11 months after IVIG therapy because the necessary number of antibodies may not be produced by the body to create lifetime immunity. "It is not likely that my child will recover from the disease." Most children with Kawasaki disease completely recover after receiving treatment. Prognosis is related to the extent of cardiac damage, but death is very rare. "I should report unusual irritability once we are home." Irritability is a hallmark sign of Kawasaki disease in children and may persist for one to two months after symptoms begin. This is expected and does not need to be reported.

Measles (Rubeola)

Measles is very contagious and spreads very quickly, especially in areas with numerous children. Education on the transmission of the disease will include length of time individuals have been exposed, contagious periods, exposure guidelines, and vaccination recommendations. An exposure to measles occurs if the individual shares the same space with an infected individual or share the same space up to 2 hours after the individual left the space. Depending on local public health department suggestions, children and adults exposed to measles who do not have proof of immunization should stay home 5-21 days after exposure in order to prevent spread of the disease. Closure of school systems is always at the discretion of the local public health department in conjunction with the school district. There is not a national law that dictates this closure. Unvaccinated individuals who have been exposed to measles should call their health care provider or public health clinic as soon as possible to receive the vaccination and decrease the risk of contracting the disease. An individual is contagious 4 days before and 4 days after the onset of the rash. The child would need to be out of class at least 4 days after the onset of the rash and at the discretion of the public health department. Child tested positive for measles, teach parent: "Unvaccinated children who have been exposed should receive the vaccine as soon as possible." Unvaccinated individuals who have been exposed to measles should call their health care provider or public health clinic as soon as possible to receive the vaccination and decrease the risk of contracting the disease. "If your child contracts measles, the child must remain out of the class for 4 days after the onset of the rash." An individual is contagious 4 days before and 4 days after the onset of the rash. The child would need to be out of class at least 4 days after the onset of the rash and at the discretion of the public health department. DON'T: "Your child's school will always close following a confirmed case of measles." Closure of school systems is always at the discretion of the local public health department in conjunction with the school district. There is not a law or regulation that dictates this closure. "Exposed children without proof of immunization are kept home for 24 hours after exposure." Depending on local public health department suggestions, children and adults exposed to measles who do not have proof of immunization should stay home 5-21 days after exposure in order to prevent spread of the disease. "Your child is exposed after sharing the infected individual's space up to 12 hours after the individual left the space." An exposure to measles occurs if the individual shares the same space with an infected individual or share the same space up to 2 hours after the individual left the space.

HPV vaccine

Providing information on vaccinations is an important role the RN plays. Education on the vaccine itself as well as education on aftercare are important aspects of care. Aftercare instructions on the administration of the HPV vaccine should include instruction for the adolescent to lie down for approximately 15 minutes after vaccination to avoid fainting and injuries due to a fall. After care: "Lie down for fifteen minutes after the injection." A common side effect to the HPV vaccine is lightheadedness and fainting. Encourage the adolescent to lie down for 15 minutes after vaccination to help prevent fainting and falls. NOT: "Rub the vaccination site gently for one minute." It is not necessary or recommended to rub or massage the HPV vaccination site. This action does not increase its absorption or efficacy. "Avoid large crowds for about a week." It is not necessary or recommended that individuals avoid large crowds after HPV vaccination. "Limit your activity level today and tomorrow." Activity limitation is not recommended or necessary after HPV vaccination.

rheumatic fever

Rheumatic fever is an infection that can affect the heart, joints, brain, and skin if treatment is not prompt. It can be caused by bacterial infection with A. streptococcus that occurs with scarlet fever or strep throat. Rheumatic fever is not contagious, although the causative factors of scarlet fever and strep throat associated with A. streptococcus are. The condition is more common in children ages five to fifteen than in adults. Symptoms may be treated with medications such as aspirin, a nonsteroidal anti-inflammatory drug, but the condition itself is treated with antibiotics. Prescription for treatment: Antibiotics Antibiotics are used to treat rheumatic fever, as the cause is a bacterial infection. NOT: Antipyretics Antipyretics treat fever, a symptom of rheumatic fever, but are not used to treat the condition itself, as the causative factor is a bacteria. Antiarrhythmics Antiarrythmics are not used to treat rheumatic fever, as the cause is bacteria and antiarrythmics are used for cardiac dysrhythmias. Antiemetics Antiemetics are a group of drugs used for the prevention and treatment of nausea and vomiting and are not used to treat rheumatic fever.

Rubella (German Measles)

Rubella, also known as German measles, is a disease caused by the Rubella virus. Most people are immunized against it with the measles, mumps, and rubella (MMR) vaccine. Rubella causes joint pain, fever, headache, and a rash. Acetaminophen can be used to reduce the fever and relieve joint pain. Antihistamines can be administered to relieve pruritus.Rubella is distinct from rubeola (measles). Rubeola starts with fever, runny nose, cough, red eyes, and sore throat. Rubella is generally a milder disease that mostly affects the skin and lymph nodes. Give: Acetaminophen Acetaminophen may be used to reduce fever and joint pain associated with measles. Diphenhydramine Diphenhydramine or other antihistamines may be prescribed to relieve pruritis. NOT: Codeine syrup Codeine syrup might be prescribed for the client with rubeola (measles) for cough, but not rubella. Dextromethorphan A cough is associated with an outbreak of rubeola (measles) and not rubella (German measles); there would be no reason to anticipate this prescription. Erythromycin An antibiotic is not indicated for an outbreak of the measles virus. Rubella, also known as German measles, is a disease caused by the rubella virus. Most people are immunized against it with the measles, mumps, and rubella (MMR) vaccine. Rubella causes joint pain, fever, headache, and a rash which starts on the face and spreads downwards. Acetaminophen (Tylenol), an analgesic, can be used to reduce the fever and relieve joint pain. Parents should be informed that the virus is usually benign, and complications are rare. Proper precautions should be instituted to avoid transmission of the virus to others. Intervention: Uses droplet precautions when caring for the client. Droplet precautions should be used because rubella is primarily transmitted via nasopharyngeal secretions. NOT: Administers codeine sulfate to relieve joint pain. Codeine sulfate (Codeine) and other opioid medications are not recommended for the mild symptoms caused by rubella. Administers a cough suppressant as prescribed. Administering a cough suppressant is an intervention for rubeola (measles), which causes cough and runny nose. Tells the parents the rash may take several weeks to resolve. The rash associated with rubella typically resolves by the third day.

Scarlett Fever (group A strep)

Scarlet fever is caused by the group A Streptococcus bacteria. The same bacteria is responsible for other infections such as strep throat. Scarlet fever is spread by droplet transmission or by touching areas of a person's body that contain the bacteria such as the nose, mouth, or eyes. Initial symptoms include fever, sore throat, chills, and vomiting. The throat and tonsils may swell, and the face may appear flushed with pale areas around the mouth. The tongue may also appear red and bumpy. A rash appears on the neck, underarms, and groin area first, then spreads over the entire body. Characteristics of the rash include small, flat red blotches that progress to a sandpaper-like appearance. Treatment consists of antibiotics, and prevention includes hand washing. Currently, no vaccine exists to prevent the contraction of scarlet fever. The nurse cares for a toddler-age client who develops a fever, sore throat, and a red, macular rash. Inflamed tonsils and a red tongue is also present. Based on these findings, the nurse follows the protocol for which disease? CORRECT: Scarlet fever Scarlet fever is associated with fever, sore throat, red rash, inflamed tonsils and a red tongue. Symptoms are due to the bacterial infectious process. The red rash is the result of toxins produced by the bacteria. WRONG: Pertussis Early symptoms of pertussis (whooping cough) include a runny nose, apnea, mild cough, and low-grade fever. Later symptoms involve rapid coughing fits, vomiting, and exhaustion from excessive coughing. Diphtheria Symptoms of diphtheria include nasopharyngitis, obstructive laryngotracheitis, and vaginal, otic, skin, or conjunctival lesions. The disease is rare in the United States. Mumps Symptoms of mumps include fever, anorexia, earache, and swelling of the parotid gland, Scarlet fever is caused by streptococcus pyogenes and most commonly affects children age 4 to 8 years. The symptoms of scarlet fever begin abruptly and include fever, sore throat, rash, and a bright red tongue. The rash appears 12 to 72 hours after the onset of a fever. The tonsils are inflamed and often covered with a white coating. A nurse in a pediatric clinic completes an initial assessment on a 5-year-old girl. The child has a temperature of 103.1 F (39.5 (C) and has a red, macular rash on her chest and abdomen. The mother reports the child has been crying with a sore throat and physical examination reveals inflamed tonsils and a red tongue. The nurse anticipates the provider will confirm which diagnosis based on these findings? Scarlett fever.

sickle cell disease

Sickle cell disease is a hereditary disorder in which a mutated form of hemoglobin causes red blood cells to take on a sickle-shape under low oxygen conditions. The sickled cells occlude vessels, creating a multitude of symptoms such as pain, cardiovascular changes, priapism, skin, abdominal, kidney, musculoskeletal, and central nervous system changes. Sickling occurs with dehydration, infection, venous stasis, pregnancy, alcohol consumption, high altitudes, low or high body temperatures, strenuous exercise, emotional stress, anesthesia, and under conditions that compromise oxygenation. Pain associated with sickle cell crisis is due to tissue injury resulting from poor perfusion and diminished gas exchange. This is preceded by obstructed blood flow resulting from occlusion by the sickle-shaped red blood cells. Pain management includes keeping the client hydrated, drug therapy, and other complementary therapies such as relaxation and distraction techniques. BEST for clients pain: Provides oral hydration Hydration, either orally or intravenously, helps to prevent sickling, which thereby helps reduce pain. NOT: Administers acetaminophen Clients in sickle cell crisis are often in significant pain, and stronger analgesia is prescribed, such as hydromorphone (Dilaudid), an opioid. Provides oral hydration Hydration, either orally or intravenously, helps to prevent sickling, which thereby helps reduce pain. Encourages bed rest Bed rest is not the best intervention for managing pain associated with sickle cell crisis. Places client in the fetal position Clients should keep the extremities extended to promote venous return. Poor oxygenation and circulation cause more sickling, which continues the cycle of pain. In sickle cell anemia, a vaso-occlusive crisis occurs when sickle-shaped red blood cells become lodged in small capillaries, occlude them, prevent blood flow, and cause ischemia. The nurse should immediately take action to increase perfusion and oxygenation to the affected extremities. Administering oxygen, IV fluids, and blood products are the top priorities. PRIORITY: Delivering oxygen by nasal cannula as prescribed Increased perfusion and oxygenation are the top priority, and they can be done by the adminstration of oxygen and infusion of IV fluids or blood products. NOT: Assisting the client to a side lying position when resting The client should be positioned with extremities extended to promote venous return; side-lying encourages flexed arms and legs and should be avoided. Encouraging the client to maintain bed rest Bed rest is important to conserve energy but is not the priority. Administering prescribed analgesics Pain medications are important for relief of discomfort but are not the priority. Symptoms of sickle cell anemia are the result of the sickle-shaped red blood cells obstructing circulation, of vascular inflammation, and of an increase in the destruction of red blood cells. Microcirculation is obstructed, causing vaso-occlusion and subsequent tissue hypoxia. The result is tissue ischemia and cellular death. Manifestations of the disease are diffuse and are the result of this pathophysiological process. Cause of symptoms: Obstruction by red blood cells Red blood cells cause vasoocclusions due to their stiffness and sickle shape. NOT: Elevated serum bilirubin levels Elevated bilirubin is a symptom, not the cause of symptoms, due to the rapid death of red blood cells and the liver's inability to keep up with filtering them out. Vitamin B12 deficiency Vitamin B12 deficiency is associated with vitamin B12 deficiency anemia, not sickle cell anemia. Decreased red blood cell production Decreased red blood cell production is not the cause, but red blood cell destruction does occur in the spleen. Sickle cell anemia involves vaso-occlusive obstruction with sickle-shaped red blood cells, vascular inflammation, and increased red blood cell destruction. Obstructed microcirculation results, then vaso-occlusion and subsequent tissue hypoxia. Situations should be avoided in which hypoxia may be triggered, such as dehydration, high altitudes, extreme temperatures, strenuous activity, unpressurized airplanes, and illness. Require teaching: "The airplane on the way to Colorado should be pressurized." Airplane cabins are pressurized to promote oxygenation, but visiting high-altitude places should be avoided, as oxygen levels are lower at high altitude and can cause a sickle cell crisis. OK: "We will not let our child play out in the snow too long this winter." Extreme temperatures should be avoided, as this can lead to a sickle cell crisis due to vasoocclusion. "We should always make sure our child stays well hydrated." Staying well-hydrated helps to avoid a sickle cell crisis because dehydration promotes sickling of red blood cells. "Our child should avoid strenuous activities." Strenuous activity should be avoided, because it can cause a sickle cell crisis due to increased oxygen demands.

Femoral Central Line

The CDC recognizes central catheter related infections as a risk of having a central line. The femoral site has a higher incidence of infection than the subclavian or jugular site. Also, emergent line placement increases the risk of infection. Sterile technique at insertion, proper hand hygiene, and early removal of the catheter are a few of the CDC's recommendations to decrease central catheter infections. Infection is a delayed complication from central catheter placement. Arrhythmia, hemorrhage, and pneumothorax typically occur soon after insertion. A client receives an emergent central catheter to the femoral vein. During the following week, what complication does the nurse assess for? CORRECT: Infection Infection is the most likely complication to occur within the week after insertion at the femoral site. Emergent lines are not always placed with the best technique and may lack sterility. Additionally, the femoral site is prone to microorganism contamination. WRONG: Hemorrhage Hemorrhage is most likely to occur at the time of initial insertion, not days after insertion. Pneumothorax A pneumothorax may be a complication seen with subclavian line placement in the chest, but would not be a complication of a femoral line placement in the leg. Arrhythmia Arrhythmias are most likely to occur when the guide wire enters the right atrium of the heart at the time of central line insertion. However, the guide wire does not enter the heart with a femoral central line insertion site.

polio vaccination

The inactivated polio vaccine is currently given to healthy infants in four doses: at two months, at four months, between six and eighteen months, and between four and six years old. The nurse reviews an immunization schedule with the parent of an infant at the 2-month checkup, who has just received a polio vaccination. At which visits will the infant receive additional polio vaccination? CORRECT: Four years The client will receive the fourth and final dose of the series between four and six years of age. Fifteen months The child will receive the third dose in the four-dose series between six and eighteen months of age. Four months The infant client will receive the second dose in the four-dose series at four months of age. NOT: Two years Two years of age is not a recommended age for one of the doses in the four-dose series. Three months Three months is not a recommended age for one of the four doses in the series.

Protein on Hemodialysis

The recommended protein intake for clients on hemodialysis is at least 1.2g/kg of ideal body weight per day and may be increased depending on the client's individual needs. Wtih the average adult weight of 62 kg, this would call for 74.4 g of protein daily. High-protein foods are recommended. All clients with chronic kidney disease (CKD) should be referred to a registered dietitian for nutrition education and guidance. Dietary protein guidelines for peritoneal dialysis are higher than those with hemodialysis because of protein loss in the dialysate (2-3 g/kg/day; 0.5 g/kg/day; 1.2 g/kg/day */ 0.6 to 1 g/kg/day). YES: Raisins Raisins are high in protein, with 3.1 g per quarter-cup. Veggie burgers Veggie burgers are high in protein, with 11 g per 70 g patty. Chicken Chicken is high in protein, with 31 g per 100 g serving. NO: Leafy green salad Though leafy green vegetables have some protein, they are not high in protein, at 0.9 g per cup. Strawberries Strawberries are low in protein, with 0.1 g per medium strawberry.

HIV--> mom to baby

The use of antiviral medications is critical in the prevention of parent-child transmission of HIV during all phases of pregnancy. Effective treatment greatly reduces the risk of viral transmission, and many children born to HIV-positive parents never contract the virus. Modes of transmission: Transmission from placental blood flow while the fetus is in utero Transmission in utero occurs at varying rates, and most infants are not infected. A breakdown of the integrity of the placenta in the third trimester is thought to lead to transmission of parental blood to the fetus. Exposure to parental blood and body fluids during delivery The parent giving birth is the source of the virus, and, depending on viral load counts, transmission during delivery when blood and body fluids are present is possible. Transmission through breast milk when breastfeeding Transmission via breast milk is possible and the risk must be balanced between need for nutrition and risk for infection. This can be determined by viral load counts while being treated with antiviral medication. NOT: Exposure to amniotic fluid with rupture of membranes. Amniotic fluid does not pose an increased risk for HIV transmission. Close contact such as kissing the infant or sleeping in the same bed Casual contact and kissing do not pass on the HIV.

Varicella (chicken pox)

Varicella (chickenpox) is a contagious viral disease that is usually mild but can be serious in certain populations, including infants, pregnant clients, and those with compromised immune systems. The varicella vaccine is a live virus vaccine and may be administered to children with a mild episodic illness, such as a mild upper respiratory tract infection. Children should receive two vaccination doses at 12-15 months of age and again at four to six years of age. It is contraindicated in someone with severe, life-threatening allergies to vaccine components, blood disorders, or moderate to severe illness, who is receiving immunosuppressive therapy, or who is currently pregnant. Re-schedule a visit: The infant client has just completed testing for leukemia and the results are not yet verified. Leukemia is a contraindication for receiving the varicella vaccination and the vaccine should be postponed until results are verified. DON'T: The infant client has an older sibling at home who contracted chickenpox last month. A sibling with previous disease is not an indication to postpone the vaccination. The infant client is irritable and fussy, with a temperature of 99.8 °F (37.1 °C) and evidence of two new teeth. Temperature elevation is expected when teething and is not an indication to postpone the vaccination. The infant client has had a cough and runny nose with clear drainage for the last 24 hours. A mild illness, including a cold, is not an indication to postpone the vaccination.

Pertussis (whooping cough)

Young infants are especially at risk for respiratory complications of pertussis. Therefore, continuous cardiorespiratory monitoring is essential, especially noting bradypnea which can be a precursor to apnea. Antibiotics are given to treat pertussis itself, with monitoring of the complete blood count to note increased WBCs, a possible sign of pneumonia, a complication of pertussis that may necessitate additional antibiotics as well as additional respiratory support. Reverse isolation is not indicated as part of the plan of care with pertussis. A newborn client is admitted with a diagnosis of pertussis after a three-day history of paroxysmal coughing and nasal symptoms. Which intervention does the nurse include in the plan of care? Interventions: Evaluate the white blood cell (WBC) count. A rising WBC count (30,000/mm3) is associated with pneumonia, a complication of pertussis that is often acute and severe in very young infants. Monitor vital signs every hour. Deterioration in cardiorespiratory status must be recognized early in order to ensure adequate oxygenation and perfusion. Monitor for apneic spells. Infants 6 weeks' of age often experience apnea in the paroxysmal stage of pertussis. Administer antibiotics. In infants 1 month of age, the recommended agent is azithromycin, 10 mg/kg per day in a single dose for 5 days. NOT: Maintain airborne transmission precautions. In addition to universal precautions, droplet precautions, not airborne transmission precautions, are required for 5 days after initiation of antibiotics or until 3 weeks after the onset of paroxysmal coughing if appropriate antimicrobial therapy is not given.