CHAPTER 3 Acute Conditions
The number of school-age children who come to school with an acute illness is difficult to estimate. Frequently, nurses in the school and community setting are the first called on to determine whether a health problem exists and if further assessment is required. Thus the nurse must be aware of signs and symptoms of individual illness, must be able to provide the necessary initial management, and must make appropriate and informative referrals for additional treatment when necessary. Initial management information in this chapter gives the nurse a plan of action. After assessing the problems, the nurse frequently must provide health care and comfort until a parent assumes responsibility or there is additional medical intervention.
BLEPHARITIS
A. Blepharitis is a chronic or long-term inflammation of the eyelid margins or the eyelash follicles. It can affect any age individual.
A. This condition may be seborrheic, staphylococcal, or a combination of the two; or it may be an allergic reaction. Anterior blepharitis affects the external front of the eyelid, where the eyelashes are attached. Most common causes are bacteria and scalp dandruff. Posterior blepharitis affects the inner eyelid, which is the moist part that touches the eye. It is caused by problems with the oil glands in this part of the eye, usually due to one of two skin disorders, acne rosacea and seborrheic dermatitis.
III. Signs, Symptoms, and History
D. Common symptoms are burning, itching, irritation, dry eyes, excessive tearing, blurred vision; eye pain is rare.
E. Staphylococcal blepharitis: ulceration of lid margin, lashes often fall out; conjunctivitis and superficial keratitis are associated.
A. Wash hands. Cleanse the lid margins using a moistened cotton applicator, cotton ball, or cloth with diluted baby shampoo to remove scales and crusts. This is an important treatment modality, and the student can learn how to do the daily cleansing when the nurse cleans the area and teaches at the same time.
B. For seborrheic blepharitis: examine scalp, body, and eyebrows to determine if student and parent need information regarding control of seborrhea; concurrent treatment may be needed.
C. For staphylococcal blepharitis: an antistaphylococcal antibiotic is applied to the eye margins or directly into the eyes.
A. Treatment of staphylococcal blepharitis is usually continued for a week or more after symptoms have disappeared. The student may need the antibiotic administered at school. Box 3-1 explains how to administer the eye ointment. Unless the seborrheic condition is so severe that it is limiting, the student may remain in school while under treatment.
CONJUNCTIVITIS
A. Conjunctivitis, commonly called pinkeye, is a contagious inflammation of the conjunctiva, the mucous membranes that line the upper and lower eyelids and extend over the sclera. The most common pediatric ocular condition, more than 50% of the time the cause is bacterial, and it is most often diagnosed in preschool children and sexually active teens.
A. Conjunctivitis is caused by the bacteria H. influenzae, S. pneumoniae, and chlamydia and also by viruses, such as adenovirus, herpes simplex virus (HSV), herpes zoster, and enterovirus. Seasonal pollens, chemical irritants, and other allergens may also be to blame.
III. Signs, Symptoms, and History
B. Determine if viral, bacterial, or allergic conjunctivitis, or if other serious conditions are indicated. Does student appear ill other than the eye condition? Does the student complain of headache, fever, sore throat, joint pain, nausea, or a runny nose?
C. Obtain history of current problem. Did it just start? Has there been any exposure to chemicals, eye trauma, or allergens? Is there discharge, pain, or tenderness around the eye?
E. Refer to eye specialist if visual loss, moderate to severe pain, history of HSV conjunctivitis, or recurring conjunctivitis occurs.
A. Bacterial and viral conjunctivitis are transmitted by contact with the discharge from the conjunctiva or upper respiratory tract of infected persons or by contaminated fingers, clothing, or other articles.
B. Treat bacterial conjunctivitis with topical antibiotic, ophthalmic solution, or ointment (e.g., erythromycin, sulfacetamide, chloramphenicol). In certain cases bacterial conjunctivitis is self-limiting, and the viral kind should clear on its own. For allergic conjunctivitis, treat with naphazoline (OTC); discuss with parent regarding referral to allergist.
DIAPER DERMATITIS
A. Diaper dermatitis is an inflammatory irritation of the skin that causes a breakdown of this natural barrier.
A. Diaper dermatitis is caused by prolonged exposure of the skin to urine and/or feces; a sensitivity to such things as disposable diapers, soaps, and detergents; infrequency of diaper change; inappropriate or no cleansing of the diaper area; or skin dermatoses, which are aggravated by wearing diapers; reaction to medication, such as antibiotics.
III. Signs, Symptoms, and History
D. Use ointment when skin is dry; use protection for skin irritation such as zinc oxide or petroleum jelly. Hydrocortisone may be prescribed by HCP if not a fungal infection.
A. Differential diagnosis includes bacterial, viral, or candidiasis infections; psoriasis; atopic dermatitis; scabies; or seborrhea.
B. Management is difficult with children who seem predisposed to diaper dermatitis. Complete healing can take several days. However, definite improvement should be observed within 48 to 72 hours after treatment has begun.
DIARRHEA
A. Diarrhea is the passage of excessive fluid and electrolytes in the stool. This condition may be acute or chronic. Chronic diarrhea is an increased frequency of unformed stool lasting longer than 2 weeks.
1. Inflammatory processes.
a. Inflammatory processes include any surgical procedure or condition that has the ability to change the anatomy and functional integrity of the intestine, such as bacterial invasion (E. coli, celiac sprue, and irritable bowel syndrome).
2. Motility disorders.
a. Acute diarrhea can result from any atypical peristalsis from any source. Motility disorders may be either delayed or rapid and can be associated with infection or bacterial overgrowth.
III. Signs, Symptoms, and History
C. Dehydration, including decrease in urine output with increased concentration; sunken eyes; weight loss; no or few tears with crying; dry oral mucous membranes; and depressed fontanel in the infant.
C. Note any vomiting, abdominal cramping, irritability, loss of appetite, fever, or other signs of distress.
F. Suggest BRAT diet: bananas, rice, applesauce, and toast or tea. Progress to regular diet on the third day, adding soft foods.
A. Student generally will not be dismissed for one or two loose stools unless other signs of illness exist.
WEB SITES
National Institute of Diabetes and Digestive and Kidney Diseases http://www.niddk.nih.gov
Food Allergy and Anaphylaxis Network http://www.foodallergy.org
ECZEMA (ATOPIC DERMATITIS)
A. Eczema is an acute or chronic cutaneous inflammatory condition characterized by pruritus, swelling, blistering, oozing, and scaling of the skin.
A. There is a strong family predisposition. The most predominant indicator is a family history of asthma, eczema, or hay fever. Infants with atopic dermatitis (AD) seem to develop allergic rhinitis and subsequent asthma. AD affects 10% to 20% of all infants and nearly half of these children will greatly improve by ages 5 to 15. Others will have some form of atopic disease the rest of their life (American Academy of Dermatology, 2005).
B. The underlying problem is the skin’s inability to retain adequate amounts of water; can be triggered by ingestion of, or contact with, a substance to which an individual is sensitive (e.g., milk, fish, eggs, or inhalation of dust, pollen, or similar substances).
III. Signs, Symptoms, and History
B. Chronic lesions or red macular areas on face, neck folds, scalp, hands, behind ears, antecubital and popliteal areas.
C. Erythematous papules, vesicles, pustules, scales, crusts, or scabs, alone or in combination; they may be dry or occur with watery discharge (see color plates, Primary and Secondary Skin Lesions).
1. Teach avoidance of trigger allergens and extreme temperatures; sweating leads to itching and irritation.
3. Colloidal bath (Aveeno, oatmeal, or cornstarch) will soothe dry, itchy skin: use 1 to 2 cups cornstarch in a bathtub of water.
4. Limit bathing time to 5 to 10 minutes to prevent depletion of natural skin oils. Apply ointment, such as petroleum jelly, immediately to moist skin.
6. Antihistamines may be prescribed to decrease itching, such as hydroxyzine (Atarax) and diphenhydramine (Benadryl). Can cause drowsiness, but may help some children.
ERYTHEMA INFECTIOSUM, HUMAN PARVOVIRUS INFECTION (FIFTH DISEASE)
A. Erythema infectiosum is a mild, nonfebrile erythematous skin eruption that usually occurs in children from age 2 to 13 years, but it can occur in adults. Usually seen in late winter and early spring, but it can occur anytime. It is named fifth disease because it was the fifth eruptive rash characterized.
A. Fifth disease is caused by the human parvovirus B19, transmitted in blood and respiratory secretions from an infected individual.
III. Signs, Symptoms, and History
D. Prodromal phase: Rash preceded by low-grade fever (up to 102 degrees), malaise, sore throat, and headache.
E. Secondary stage: Face has “slapped cheek” appearance, erythema, and a pallor that lasts 1 to 2 days (see color plate 1).
F. Over the next several days, appearance of “lacy rash,” a maculopapular eruption that progresses from proximal to distal surfaces of the trunk and extremities.
H. Rash may reappear months later in response to sunlight, temperature extremes, exercise, trauma, or emotional stress.
D. Educate teachers and staff of childbearing age, including those working in preschools; see “Additional Information.”
A. Laboratory test used for detection is B19-specific immunoglobulin M (IgM)-antibody assay. When assay is positive, it only indicates infection within the past several months.
B. In older students and adults, arthralgias and arthritis are associated with B19 parvovirus. Affected joints in the hands may be the only symptom. Joint symptoms and rash generally occur 2 to 3 weeks after infection and can persist for many months afterward.
C. Fifth disease may be dangerous to the fetus of pregnant women who contract the disease in the first half of pregnancy. There is a risk for an infected fetus to develop fetal anemia and hydrops fetalis (massive edema), and fetal death is possible. Alert pregnant women and students to contact their HCP regarding these risks.
WEB SITE
National Center for Infectious Diseases http://www.cdc.gov/ncidod/diseases/children/diseases.htm
FEVER
A. Fever is an elevation of the body’s normal temperature, which ranges from 96.8° to 99.5° F (36° C to 37.5° C) when taken orally. If axillary measurement is used, add one degree to the reading. If the temperature is taken rectally, subtract one degree from the reading.
C. Temperature can be temporarily affected by age, physical activity, ovulation, and emotional stress.
A. A fever develops in response to a disturbance in the homeostatic mechanisms of the hypothalamus, where a balance between heat production and peripheral heat loss is maintained. Pyrogens, protein substances released by leukocytes, are produced within the body whenever inflammatory and infectious processes occur.
B. In inflammatory processes—such as those that occur in tissue damage, cell necrosis, malignancy, antigen–antibody reactions, and rejection of transplanted tissues—fever is due to the action on endogenous pyrogens, which act on the thermoregulatory center in the hypothalamus. Exogenous pyrogens occur when the body is invaded by bacteria, viruses, fungi, and other types of infectious organisms (Johnson and Baltimore, 2006).
III. Signs, Symptoms, and History
B. This reaction produces thirst, increased respirations—4 breaths per minute per degree of temperature increase—and an increased pulse rate of about 8 to 10 beats per minute for each degree of temperature increase.
C. Rapidly rising fever may cause a febrile seizure, most commonly in infants and young children under age 5; onset of seizure is sudden. (SeeChapter 4, Chronic Conditions, Seizures.)
D. Should fever persist, fluid and electrolyte losses are more severe; evidence of cellular dehydration and delirium may occur in older individuals.
B. Take temperature, vital signs, and assess behavior: note if the student is busy, talkative, tired, energetic, playing, or experiencing decreased appetite. Ask students to describe how they feel and what they did that morning.
F. Chills raise body temperature, so when they are present, a student should be covered and protected from drafts.
I. Sponge with tepid water, only uncovering small areas. When skin cools, accompany sponging with rubbing to encourage circulation of blood through skin.
J. Continue sponge bath as long as necessary to lower the temperature; a quick splash may only stimulate heat production.
A. Student with a temperature of 101° F (38.3° C) or above may be dismissed from school (American Academy of Pediatrics, 2006).
B. If student appears well and fever is low-grade, consider other factors, such as recent exercise or emotional state. Retake temperature in 15 minutes.
C. Student may be readmitted to class if there has been no fever in the preceding 24 hours and no antipyretics have been taken.
A. Oral temperature is contraindicated when seizure disorder, irrational behavior, or mouth breathing exists; when infants or toddlers are involved; or when there is disease, surgery, or structural anomaly of the oral cavity.
B. There are a variety of thermometers available, ranging from simple plastic strips to digital or infrared devices. They vary in use and levels of accuracy. Digital is more accurate than plastic strips but more expensive; electronic is safe and useful for pediatrics, and keeping the mouth closed is not required for an accurate reading; infrared are used frequently but accuracy debate continues.
FROSTBITE
A. Frostbite is an injury to the tissues and impaired circulation to the affected area, which can lead to cell destruction. Areas that are prone to freeze first are the cheeks, nose, ears, fingers, toes, and feet.
A. In prolonged exposure to cold ranging from -2 degrees to -10 degrees, nerve, blood vessel, and other cells are temporarily frozen. Many factors can potentiate effects of cold, including fatigue, injury, immobility, dependency of the extremity, general health, duration of exposure, high altitude, and increased wind velocity. Frostbite can be mild to severe, and exposure to extremely cold chemicals—such as liquid oxygen—produces immediate frostbite.
III. Signs, Symptoms, and History
4. Bullae and vesicles that appear within 24 to 48 hours; however, if necrosis of tissue occurs from inadequate circulation in involved areas, blisters do not occur.
A. Take temperature to determine presence of hypothermia, a life-threatening condition in which body core temperature is at or below 95° F (35° C).
E. If there is no possibility of refreezing, warm area rapidly, but do not use dry heat, such as a radiator or oven. Clothing, blankets, or another body surface may be used. Skin may blister, swell, and turn red, blue, or purple. An area is thawed when it is no longer numb.
A. Educate school staff and students; send newsletters home to parents and caregivers regarding prevention and initial management of frostbite.
B. To prevent frostbite, make sure children wear several layers of loose, protective clothing, such as face masks, hats, earmuffs, mittens, and appropriate boots. Have extra socks, mittens, and hats on hand; mittens are usually warmer than gloves. During severe cold weather, check children’s cheeks and hands periodically for symptoms of frostbite. If there are suspicious signs, warm the affected area with body heat; instruct the child to tuck cold hands under their armpits or into the bends of their legs.
GIARDIASIS
A. Giardiasis is a protozoan infection of the small intestine and duodenum. It ranges from asymptomatic infection to acute or chronic diarrhea and malabsorption. Giardia is the most commonly identified intestinal parasite in the United States (Childers, 2005).
A. Giardiasis is caused by the flagellate protozoan Giardia lamblia, also called Giardia intestinalis.
III. Signs, Symptoms, and History
C. Transmission is by direct person-to-person contact or by contact with contaminated food and water. Can be epidemic in day care centers and custodial institutions.
G. Limited phase of acute infection with or without anorexia and weight loss, nausea, and low-grade fever.
I. Initially watery stools, which later become greasy (steatorrhea), malodorous, and may float. No blood or mucus in stools.
B. Exclude children and adults from school if laboratory tests are positive and diarrhea is untreated.
C. Readmit student after diarrhea has stopped or treatment has started: check school or state guidelines and Department of Health standards, because these vary among states.
Box 3-2 Disinfectant Solution
One-quarter cup bleach (5.25% sodium hypochlorite) per gallon of cool water
One tablespoon bleach per quart of cool water
HAND, FOOT, AND MOUTH DISEASE
A. This highly contagious viral disease is characterized by pharyngitis, fever, and exanthem, particularly on the hands and feet. More common in the summer and early autumn and in children under age 10. Hand, foot and mouth disease (HFMD) is also known as enteroviral vesicular stomatitis with exanthema.
A. Coxsackie virus A16 is the major cause, but group B enterovirus 71 is another causative factor, is more severe, and has been associated with meningitis, encephalitis, and paralytic disease.
III. Signs, Symptoms, and History
B. Period of communicability is during the acute phase of illness but can be longer; virus persists in feces for several weeks.
C. Transmission is from person to person by direct contact with nose and throat secretions or stools of infected persons.
E. Symmetrical maculopapular eruptions on palms and soles, oral lesions, and lesions that may occur on buttocks.
F. Virus may produce vesicular lesions on palms, fingers, soles of feet, and buttocks without oral lesions. Lesions more frequent on the dorsal surfaces of hands and feet.
A. Another viral disease caused by the Coxsackie virus A16 is vesicular pharyngitis, commonly called herpangina or aphthous pharyngitis. Herpangina is an acute, self-limiting disease with sudden onset, fever, sore throat, and small, discrete, grayish vesicular pharyngeal lesions on an erythematous base that progress to ulcers (see color plates, Primary and Secondary Skin Lesions). The ulcers heal spontaneously and the condition runs its course in less than 1 week.
1. HFMD differs from herpangina in that the oral lesions are more diffuse and can occur on the gums, sides of tongue, or buccal surfaces of the cheeks. Lesions rupture, leaving shallow ulcers.
HEPATITIS A
A. Hepatitis A is the most common type of hepatitis in the United States. It is an inflammation of the liver that occurs sporadically or in epidemics. About 15% of people infected with hepatitis A virus (HAV) will have prolonged or relapsing symptoms over a 6- to 9-month period (see Table 4-7, page 217).
A. Hepatitis A is caused by HAV. The highest rates of HAV are among children 5 to 14 years of age, with approximately one third of reported cases occurring among children under 15 years of age.
III. Signs, Symptoms, and History
B. Period of communicability of virus is 2 weeks prior to the onset of jaundice; probably noninfectious after the first week of jaundice, but prolonged viral excretion—for up to 6 months—has been reported in children.
C. Transmission of HAV is by the fecal–oral route with the virus transmitted from person to person between household contacts, sex partners, or by contaminated food or water.
J. Prodromal phase: fever, anorexia, nausea and vomiting, malaise, abdominal pain, headache, enlarged or tender liver.
K. Icteric phase (5 to 7 days after initial symptoms): sclera and skin are jaundiced, urine is darkened, stools are light-colored.
E. Dispose of feces in a sanitary manner. Infants and young children can shed the virus for longer periods.
F. Determine what health education is needed in the school and community. Support family and stay in close contact.
G. Refer close contacts to their HCP or Public Health Department (PHD) for information regarding immunoglobulin.
H. Inform and educate all school staff who may be at risk (e.g., special health services staff, custodians, bus transportation personnel) of any necessary cleaning or precautions.
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