Health Problems of Toddlers and Preschoolers

Health Problems of Toddlers and Preschoolers

Learning Objectives

On completion of this chapter the reader will be able to:

• Describe the major characteristics of communicable diseases of childhood.

• List three principles of nursing care of children with communicable disease.

• Describe the nursing care of the child with conjunctivitis.

• Distinguish between aphthous stomatitis and herpetic gingivostomatitis.

• Outline a teaching plan designed to prevent transmission of intestinal parasites.

• Identify the principles in the emergency treatment of poisoning.

• Name four sources of lead in the environment.

• Describe the nursing care of the child with lead poisoning.

• State three factors thought to be associated with child abuse.

• State four areas of the history that should arouse suspicion of abuse.

• Describe the nursing care of the abused child.

http://evolve.elsevier.com/wong/essentials

Animations—Chickenpox (Varicella Zoster); Mumps

Case Studies—Bacterial Conjunctivitis; Behaviors Indicative of Future Child Abuse; Chickenpox (Varicella); Child Abuse; Heavy Metal Poisoning; Ingestion of an Injurious Agent; Salicylate Ingestion; Varicella in Spite of Vaccine

Key Points Summaries

NCLEX-Style Review Questions

Nursing Care Plan—The Child Who Is Maltreated

Infectious Disorders

Communicable Diseases

The incidence of childhood communicable diseases has declined significantly since the advent of immunizations. Serious complications resulting from such infections have been further reduced with the use of antibiotics and antitoxins. However, infectious diseases do occur, and nurses must be familiar with the infectious agent to recognize the disease and to institute appropriate preventive and supportive interventions (Table 14-1). (See also Chapter 30 for a discussion of nursing care for dermatologic conditions.)

TABLE 14-1

COMMUNICABLE DISEASES OF CHILDHOOD

DISEASE	CLINICAL MANIFESTATIONS	THERAPEUTIC MANAGEMENT AND COMPLICATIONS	NURSING CARE MANAGEMENT
Chickenpox (Varicella) (Fig. 14-1)
Agent—Varicella-zoster virus (VZV) Source—Primary secretions of respiratory tract of infected persons; to a lesser degree, skin lesions (scabs not infectious) Transmission—Direct contact, droplet (airborne) spread, and contaminated objects Incubation period—2–3 wk, usually 14–16 days Period of communicability—Probably 1 day before eruption of lesions (prodromal period) to 6 days after first crop of vesicles when crusts have formed	Prodromal stage—Slight fever, malaise, and anorexia for first 24 hr; rash highly pruritic; begins as macule, rapidly progresses to papule and then vesicle (surrounded by erythematous base; becomes umbilicated and cloudy; breaks easily and forms crusts); all three stages (papule, vesicle, crust) present in varying degrees at one time Distribution—Centripetal, spreading to face and proximal extremities but sparse on distal limbs and less on areas not exposed to heat (i.e., from clothing or sun) Constitutional signs and symptoms—Elevated temperature from lymphadenopathy, irritability from pruritus	Specific—Antiviral agent acyclovir (Zovirax); varicella-zoster immune globulin (VariZIG) or immune globulin intravenous (IGIV) after exposure in high-risk children Supportive—Diphenhydramine hydrochloride or antihistamines to relieve itching; skin care to prevent secondary bacterial infection Acetaminophen for antipyretic Complications—Secondary bacterial infections (abscesses, cellulitis, necrotizing fasciitis, pneumonia, sepsis) Encephalitis Varicella pneumonia (rare in normal children) Hemorrhagic varicella (tiny hemorrhages in vesicles and numerous petechiae in skin) Chronic or transient thrombocytopenia Preventive—Childhood immunization	Maintain Standard, Airborne, and Contact Precautions if hospitalized until all lesions are crusted; for immunized child with mild breakthrough varicella, isolate until no new lesions are seen. Keep child in home away from susceptible individuals until vesicles have dried (usually 1 wk after onset of disease), and isolate high-risk children from infected children. Administer skin care: give bath and change clothes and linens daily; administer topical calamine lotion; keep child’s fingernails short and clean; apply mittens if child scratches. Keep child cool (may decrease number of lesions). Lessen pruritus; keep child occupied. Remove loose crusts that rub and irritate skin. Teach child to apply pressure to pruritic area rather than scratching it. Avoid use of aspirin (possible association with Reye syndrome).
Diphtheria
Agent—Corynebacterium diphtheriae Source—Discharges from mucous membranes of nose and nasopharynx, skin, and other lesions of infected person Transmission—Direct contact with infected person, a carrier, or contaminated articles Incubation period—Usually 2–5 days, possibly longer Period of communicability—Variable; until virulent bacilli are no longer present (identified by three negative culture results); usually 2 wk but as long as 4 wk	Vary according to anatomic location of pseudomembrane Nasal—Resembles common cold, serosanguineous mucopurulent nasal discharge without constitutional symptoms; may have frank epistaxis Tonsillar–pharyngeal—Malaise; anorexia; sore throat; low-grade fever; pulse increased above expected for temperature within 24 hr; smooth, adherent, white or gray membrane; lymphadenitis possibly pronounced (“bull’s neck”); in severe cases, toxemia, septic shock, and death within 6–10 days Laryngeal—Fever, hoarseness, cough, with or without previous signs listed; potential airway obstruction; apprehensive; dyspneic retractions; cyanosis	Equine antitoxin (usually intravenously); preceded by skin or conjunctival test to rule out sensitivity to horse serum Antibiotics (penicillin G procaine or erythromycin) in addition to equine antitoxin Complete bed rest (prevention of myocarditis) Tracheostomy for airway obstruction Treatment of infected contacts and carriers Complications—Toxic cardiomyopathy (second to third weeks) Toxic neuropathy Preventive—Childhood immunization	Follow Standard and Droplet Precautions until two culture results are negative for C. diphtheriae; use Contact Precautions with cutaneous manifestations. Administer antibiotics in a timely manner. Participate in sensitivity testing; have epinephrine available. Administer complete care to maintain bed rest. Use suctioning as needed. Observe respiration for signs of obstruction. Administer humidified oxygen as prescribed.
Erythema Infectiosum (Fifth Disease) (Fig. 14-2)
Agent—Human parvovirus (HPV) B19 Source—Infected persons, mainly school-age children Transmission—Respiratory secretions and blood, blood products Incubation period—4–14 days; may be as long as 21 days Period of communicability—Uncertain but before onset of symptoms in children with aplastic crisis	Rash appears in three stages: I—Erythema on face, chiefly on cheeks (“slapped face” appearance); disappears by 1–4 days II—About 1 day after rash appears on face, maculopapular red spots appear, symmetrically distributed on upper and lower extremities; rash progresses from proximal to distal surfaces and may last ≥1 wk III—Rash subsides but reappears if skin is irritated or traumatized (sun, heat, cold, friction) In children with aplastic crisis, rash usually absent and prodromal illness includes fever, myalgia, lethargy, nausea, vomiting, and abdominal pain Child with sickle cell disease may have concurrent vaso-occlusive crisis	Symptomatic and supportive—Antipyretics, analgesics, antiinflammatory drugs Possible blood transfusion for transient aplastic anemia Complications—Self-limited arthritis and arthralgia (arthritis may become chronic); more common in women May result in serious complications (anemia, hydrops) or fetal death if mother infected during pregnancy (primarily second trimester) Aplastic crisis in children with hemolytic disease or immunodeficiency Myocarditis (rare)	Isolation of child is not necessary, except hospitalized child (immunosuppressed or with aplastic crises) suspected of HPV infection is placed on Droplet Precautions and Standard Precautions. Pregnant women need not be excluded from workplace where HPV infection is present; they should not care for patients with aplastic crises. Explain low risk of fetal death to those in contact with affected children; assist with routine fetal ultrasonography for detection of fetal hydrops.
Exanthem Subitum (Roseola Infantum) (Fig. 14-3)
Agent—Human herpesvirus type 6 (HHV-6; rarely HHV-7) Source—Possibly acquired from saliva of healthy adult; entry via nasal, buccal, or conjunctival mucosa Transmission—Year round; no reported contact with infected individual in most cases (virtually limited to children <3 yr but peak age is 6–15 mo) Incubation period—Usually 5–15 days Period of communicability—Unknown	Persistent high fever for 3–4 days in child who appears well Precipitous drop in fever to normal with appearance of rash Rash—Discrete rose-pink macules or maculopapules appearing first on trunk and then spreading to neck, face, and extremities; nonpruritic; fades on pressure; lasts 1–2 days Associated signs and symptoms—Cervical and postauricular lymphadenopathy, inflamed pharynx, cough, coryza	Nonspecific Antipyretics to control fever Complications—Recurrent febrile seizures (possibly from latent infection of central nervous system that is reactivated by fever) Encephalitis (rare)	Teach parents measures for lowering temperature (antipyretic drugs); ensure adequate parental understanding of specific antipyretic dosage to prevent accidental overdose. If child is prone to seizures, discuss appropriate precautions and possibility of recurrent febrile seizures.
Mumps
Agent—Paramyxovirus Source—Saliva of infected persons Transmission—Direct contact with or droplet spread from an infected person Incubation period—14–21 days Period of communicability—Most communicable immediately before and after swelling begins	Prodromal stage—Fever, headache, malaise, and anorexia for 24 hr followed by “earache” that is aggravated by chewing Parotitis—By third day, parotid gland(s) (either unilateral or bilateral) enlarges and reaches maximum size in 1–3 days; accompanied by pain and tenderness; other exocrine glands (submandibular) may also be swollen	Preventive—Childhood immunization Symptomatic and supportive—Analgesics for pain and antipyretics for fever Intravenous fluid if needed for child who refuses to drink or vomits because of meningoencephalitis Complications—Sensorineural deafness Postinfectious encephalitis Myocarditis Arthritis Hepatitis Epididymoorchitis Oophoritis Pancreatitis Sterility (extremely rare in adult men) Meningitis	Maintain isolation during period of communicability; institute Droplet and Contact Precautions during hospitalization. Encourage rest and decreased activity during prodromal phase until swelling subsides. Give analgesics for pain; if child is unwilling to swallow pills or tablets medication, use elixir form. Encourage fluids and soft, bland foods; avoid foods requiring chewing. Apply hot or cold compresses to neck, whichever is more comforting. To relieve orchitis, provide warmth and local support with tight-fitting underpants.
Measles (Rubeola) (Fig. 14-4)
Agent—Virus Source—Respiratory tract secretions, blood, and urine of infected person Transmission—Usually by direct contact with droplets of infected person; primarily in the winter Incubation period—10–20 days Period of communicability—From 4 days before to 5 days after rash appears but mainly during prodromal (catarrhal) stage	Prodromal (catarrhal) stage—Fever and malaise, followed in 24 hr by coryza, cough, conjunctivitis, Koplik spots (small, irregular red spots with a minute, bluish white center first seen on buccal mucosa opposite molars 2 days before rash); symptoms gradually increasing in severity until second day after rash appears, when they begin to subside Rash—Appears 3–4 days after onset of prodromal stage; begins as erythematous maculopapular eruption on face and gradually spreads downward; more severe in earlier sites (appears confluent) and less intense in later sites (appears discrete); after 3–4 days, assumes brownish appearance, and fine desquamation occurs over area of extensive involvement Constitutional signs and symptoms—Anorexia, abdominal pain, malaise, generalized lymphadenopathy	Preventive—Childhood immunization. Vitamin A supplementation (see p. 431) Supportive—Bed rest during febrile period; antipyretics Antibiotics to prevent secondary bacterial infection in high-risk children Complications—Otitis media Pneumonia (bacterial) Obstructive laryngitis and laryngotracheitis Encephalitis (rare but has high mortality)	Maintain isolation until fifth day of rash; if child is hospitalized, institute Airborne Precautions. Encourage rest during prodromal stage; provide quiet activity. Fever—Instruct parents to administer antipyretics; avoid chilling; if child is prone to seizures, institute appropriate precautions. Eye care—Dim lights if photophobia present; clean eyelids with warm saline solution to remove secretions or crusts; keep child from rubbing eyes. Coryza, cough—Use cool-mist vaporizer; protect skin around nares with layer of petrolatum; encourage fluids and soft, bland foods. Skin care—Keep skin clean; use tepid baths as necessary.
Pertussis (Whooping Cough)
Agent—Bordetella pertussis Source—Discharge from respiratory tract of infected persons Transmission—Direct contact or droplet spread from infected person; indirect contact with freshly contaminated articles Incubation period—6–20 days; usually 7–10 days Period of communicability—Greatest during catarrhal stage before onset of paroxysms	Catarrhal stage—Begins with symptoms of upper respiratory tract infection, such as coryza, sneezing, lacrimation, cough, and low-grade fever; symptoms continue for 1–2 wk, when dry, hacking cough becomes more severe Paroxysmal stage—Cough most common at night; consists of short, rapid coughs followed by sudden inspiration associated with a high-pitched crowing sound or “whoop”; during paroxysms, cheeks become flushed or cyanotic, eyes bulge, and tongue protrudes; paroxysm may continue until thick mucous plug is dislodged; vomiting frequently follows attack; stage generally lasts 4–6 wk, followed by convalescent stage Infants younger than age 6 mo may not have characteristic whoop cough but have difficulty maintaining adequate oxygenation with amount of secretions, frequent vomiting of mucus and formula or breast milk Pertussis may occur in adolescents and adults with varying manifestations; cough and whoop may be absent; however, as many as 50% of adolescents may have a cough for ≤10 wk (American Academy of Pediatrics, Committee on Infectious Diseases, 2009) Additional symptoms in adolescents include difficulty breathing and posttussive vomiting (See also Immunizations, Chapter 10, for discussion of pertussis immunization schedule.)	Preventive—Immunization; current belief is that childhood immunizations for pertussis do not confer lifelong immunity to adolescents and adults, so a pertussis booster is recommended for adolescents (see Chapter 10, Schedule for Immunizations) Antimicrobial therapy (e.g., erythromycin, clarithromycin, azithromycin) Supportive—Hospitalization sometimes required for infants, children who are dehydrated, or those who have complications Increased oxygen intake and humidity Adequate fluids Intensive care and mechanical ventilation if needed for infants younger than age 6 mo Complications—Pneumonia (usual cause of death in younger children) Apnea (infants <1 yr) Atelectasis Otitis media Seizures Hemorrhage (scleral, conjunctival, epistaxis; pulmonary hemorrhage in neonate) Weight loss and dehydration Hernias (umbilical and inguinal) Prolapsed rectum Complications reported among adolescents include syncope, sleep disturbance, rib fractures, incontinence, and pneumonia (American Academy of Pediatrics, Committee on Infectious Diseases, 2009)	Maintain isolation during catarrhal stage; if child is hospitalized, institute Droplet Precautions. Obtain nasopharyngeal culture for diagnosis. Encourage oral fluids; offer small amount of fluids frequently. Ensure adequate oxygenation during paroxysms; position infant on side to decrease chance of aspiration with vomiting. Provide humidified oxygen; suction as needed to prevent choking on secretions. Observe for signs of airway obstruction (increased restlessness, apprehension, retractions, cyanosis). Encourage compliance with antibiotic therapy for household contacts. Encourage adolescents to obtain pertussis booster (Tdap) (see also Immunizations, Chapter 10). Use Standard Precautions and mask in health care workers exposed to children with persistent cough and high suspicion of pertussis. Cough medicine unlikely to help and not recommended for children younger than age 2 yr (http://www.fda.gov, 2008) Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Pain Assessment and Management in Children Family Influences on Child Health Promotion Health Promotion of the Adolescent and Family The Child with Cardiovascular Dysfunction Stay updated, free articles. Join our Telegram channel Tags: Wongs Essentials of Pediatric Nursing Jan 16, 2017 \| Posted by admin in NURSING \| Comments Off on Health Problems of Toddlers and Preschoolers Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access