Johnson J., Keogh J. Pediatric Nursing Demystified: A Self-Teaching Guide
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OVERVIEW
Normal functioning of the immune system protects the body against the inva-
sion of outside microorganisms referred to as a pathogen. Two of the most
common pathogens are bacteria and viruses. An infection occurs when there
is a successful invasion of the host by a pathogen (antigen). However, for this
to happen, each link in the chain of infection must be intact.
CHAIN OF INFECTION
The chain of infection describes the elements that must be in place for the
infection to occur. These elements are
䊋 Pathogen: Sufficient number of microorganisms strong enough to enter
and survive the body.
䊋 Reservoir: The proper environment within the body to prosper must
include oxygen, water, food, and the best pH balance and temperature.
䊋 Portal of exit: The pathogen must be able to exit its existing environment.
For example, the pathogen must be able to leave the respiratory tract, gas-
trointestinal (GI) tract, or skin of its present host to infect another host.
䊋 Mode of transmission: There must be a way for the pathogen to move
from one host to another such as by air droplets, water, or contact.
䊋 Portal of entry: The pathogen must be able to enter the new host such as
through a break in the skin or via the respiratory tract.
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12 Determine who can visit a patient who has varicella.
13 Respond to a patient who has anaphylaxis.
14 Assess the signs and symptoms of mononucleosis.
Allergen
Artificially acquired active
immunity
Artificially acquired passive
immunity
Brudzinski sign
Contact isolation
Droplet isolation
Endotoxins
Exotoxins
Flora
Forescheimer spots
Incubation period
Kernig sign
Koplik spots
Macules
Myalgias
Natural immunity
Naturally acquired active
immunity
Naturally acquired passive
immunity
Papules
Parotitis
Pathogen
Prodromal
Toxoids
Urticaria
Vesicles
KEY WORDS
䊋 Susceptible host: The host’s immune system must be weak and unable
to define against the invading pathogen. A person who is very young or
very old or who has a low white blood cell count or is taking antiinflam-
matory medication typically has a weakened immune system.
STAGES OF INFECTION
The infectious process begins once the pathogen has successfully invaded
the host. There are four stages of the infectious process:
䊋 Incubation period: This is the interval between the invasion and when
the first symptoms appear.
䊋 Prodromal: This is the interval between the appearance of nonspecific
symptoms (e.g., I feel like I’m coming down with something) to when spe-
cific symptoms appear (e.g., starting to feel warm and having a headache).
䊋 Illness: This is when symptoms for a specific type of infection occur
(e.g., fever, chills, headache, running nose).
䊋 Convalescence: This is the interval when the specific systems abate (i.e.,
starting to feel better but not yet back to normal).
A GOOD DEFENSE
The immune system protects the body using one of five methods:
䊋 Natural immunity: The immune system recognizes the pathogen as a
foreign cell that attacks and destroys the pathogen using nonpathogen-
specific phagocytic action.
䊋 Naturally acquired active immunity: The immune system develops
antibodies to a pathogen once the pathogen infected the host previously.
Antibodies then attack and destroy subsequent invasion by the pathogen.
䊋 Naturally acquired passive immunity: Antibodies for specific
pathogens are passed from mother to fetus and protect the fetus for
approximately 6 months after birth until the infant’s own immune sys-
tem matures.
䊋 Artificially acquired active immunity: A low potent or dead portion of
the pathogen is introduced to the host in a vaccine causing the immune
system to develop antibodies against the pathogen. Artificially acquired
active immunity develops antibodies that last years or an entire lifetime.
䊋 Artificially acquired passive immunity: The host is administered anti-
bodies from a different host in the form of immunoglobulin such as gam-
maglobulin or convalescent serum globulin. Artificially acquired passive
immunity provides short-term protection and does not encourage the
host’s immune system to develop antibodies against the pathogen.
THE DEFENDERS
Lymphocytes are the primary cells of the immune system. Lymphocytes are
divided into B cells and T cells.
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䊋 B cells: Provide a humoral immune response because they produce an
antigen-specific antibody.
䊋 T cells: Provide a cellular immune response. Mature T cells are com-
posed of CD4 and CD8 cells. CD8 cells are responsible for destroying
foreign and viral inhabited cells, and they suppress immunologic func-
tions. CD4 cells, also known as helper T cells, stimulate immune func-
tions, such as B cells and macrophages. A macrophage is a cell whose
functions include ingesting foreign or invading cells.
VACCINATIONS
There are three types of vaccinations:
䊋 Live, attenuated: This vaccination contains a weakened pathogen.
䊋 Inactivated: This vaccination contains portions of a dead pathogen.
䊋 Toxoids: A microorganism itself might not cause an infection, but toxin
released by the microorganism might cause the infection. Toxoids are
vaccines that are a defense against the toxin.
Visit the American Academy of Pediatrics Web site (www.cispimmunize.org)
for the recommended immunization schedule for children.
Common reactions to a vaccination are: swelling, redness, and pain at the
injection site and fever of <102°F and fussiness.
Severe reactions to a vaccination that require emergency care are fever
>102°F, anaphylaxis, and persistent crying for >2 hours.
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FIGURE 14-1
Nursing alert Children who are taking corticosteroids for >2 weeks or who have
a weak immune system should not be administered live, attenuated vaccination.
Don’t administer the measles vaccine together with the tuberculin purified protein
derivative test because this might cause a false-negative test result.
BACTERIA
Bacteria adhere to mucosal surface or epithelial cells and produce proteins
that disrupt cell function or destroy cells walls. There are two types of proteins
that can be produced:
䊋 Exotoxins: Protein is released during cell growth and is affected by
antibiotics.
䊋 Endotoxins: Protein is released when the bacteria decomposes and are
not affected by antibiotics.
Flora consists of bacteria within the body that isn’t harmful under normal cir-
cumstance and in some situations helps the body in digestion and in restrain-
ing the growth of harmful microorganism.
VIRUSES
A virus is a tiny microorganism that must invade a cell in order to reproduce. Once
inside the cell, the virus modifies the cell’s normal function to propagate the virus.
Antibiotics are ineffective against a virus; however, the health-care provider may
prescribe prophylactic antibiotics because a virus infection may weaken the
patient’s immune system, creating an environment for bacteria to prosper.
A health-care provider may proscribe antiviral medication to fight the virus.
DIPHTHERIA
What Went Wrong?
Diphtheria is a bacterial infection typically of the larynx, tonsils, and nasopharynx
that is caused by Corynebacterium diphtheria. The bacterium is transmitted by
contact with discharge from a skin lesion or discharge from the nasal passages,
pharynx, or eye between 2 and 4 weeks following the onset of symptoms. Symp-
toms can take up to 7 days to appear. Diphtheria is preventable with a series of
immunizations (DTaP) that begin at 2 months of age. An infant is protected for
6 months by passive immunity if the infant’s mother has diphtheria antibodies.
Nursing alert Place the patient on droplet isolation. If lesions are present,
place the patient on contact isolation.
Signs and Symptoms
䊋 Purulent rhinitis
䊋 Cough
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䊋 Stridor
䊋 Thick grayish green lesion on the pharynx and tonsils
䊋 Pharyngitis
䊋 Fever
䊋 Malaise
Nursing alert Lesions can obstruct the airway, especially in infants who have
small airways. Removal of the lesion risks bleeding.
Test Results
䊋 Culture and sensitivity test: Positive for C. diphtheria.
䊋 Serologic test: Identifies diphtheria toxin.
Treatment
䊋 Administer diphtheria antitoxin.
䊋 Administer antibiotic (Penicillin G, erythromycin) within 3 days of the
onset of the symptoms.
Nursing alert Assess if the patient is allergic to penicillin. If there is an aller-
gic reaction, administer erythromycin.
Nursing Intervention
䊋 Place the child in droplet isolation to prevent transmission of the
disease.
䊋 Everyone must wear gowns, masks, and gloves when in contact with the
patient.
䊋 Place the child on contact isolation if lesions are present.
䊋 Monitor for signs of airway obstruction.
䊋 Maintain bed rest.
䊋 Report the diagnoses to local health officials according to policy.
䊋 Explain the disorder and treatment to the family and to the patient.
Nursing alert Isolation precautions remain in effect until two consecutive neg-
ative nasopharyngeal cultures are received.
HAEMOPHILUS INFLUENZAE TYPE B
What Went Wrong?
Haemophilus influenzae type B (Hib) is a bacterial infection caused by the
Coccobacillus H. influenza bacteria, which is secondary to an upper respiratory
viral infection. Coccobacillus H. influenza bacteria is normal flora in the upper
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respiratory tract that is restrained from infecting the body by the immune system.
However, an upper respiratory viral infection weakens the immune system suf-
ficiently for the Coccobacillus H. influenza bacteria to penetrate the mucosal
tissue and enter the bloodstream.
Signs and Symptoms
Signs and symptoms depend on which part of the body becomes infected.
Typically the infection results in bronchiolitis, epiglottiditis, meningitis, oti-
tis media, or laryngotracheobronchitis.
Test Results
䊋 Culture and sensitivity test: Positive for Coccobacillus H. influenza.
䊋 Serologic test: Identifies Coccobacillus H. influenza toxin.
Treatment
䊋 Administer antibiotic (ceftriaxone [Rocephin], cefotaxime [Calforan],
chloramphenicol [Chloromycetin]).
䊋 Administer rifampin (Rifadin) prophylatically to others who have been
in close contact with the patient.
Nursing Intervention
䊋 Place the child in droplet isolation to prevent transmission of the disease.
䊋 Provide cool humidification.
䊋 Explain the disorder and treatment to the family and to the patient.
Nursing alert Isolation precautions remain in effect until after the first 24 hours
of antibiotic treatment.
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1. A parent of a child who has a fever and is coughing is brought to the Emergency
Department (ED). You notice a lesion on the child’s tonsil. What is your best response?
a. Explain that the child probably has tonsillitis and will be fine in a couple of days
following antibiotic treatment.
b. Immediately place the child in droplet isolation until the child’s condition is
diagnosed.
c. Show the parent and child to a gurney located in the main area of the ED.
d. Show the parent and child to a gurney located in the main area of the ED and
make sure the curtain is pulled.
Answer:
✔ ROUTINE CHECKUP 1
PERTUSSIS
What Went Wrong?
Pertussis in a bacterial infection caused typically by Bordetella pertussis but
can also be caused by B. parapertussis or B. bronchiseptica that causes an
upper respiratory tract infection resulting in an irritating cough that ends in
high-pitched inspiratory whoop, which is why pertussis is commonly referred
to as whooping cough. Pertussis occurs because the patient was in contact
with contaminated respiratory droplets or in contact with items that become
contaminated by respiratory droplets. Once exposed, the bacteria incubate for
3 to 12 days before symptoms appear. Children should be vaccinated (DTaP)
against pertussis beginning at 2 months of age.
Nursing alert The patient is contagious from a week after exposure to the bacteria
through the first 7 days of antibiotic therapy.
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2. The mother of a child recently diagnosed with Haemophilus influenzae type B
looked up this disorder on the Internet and learned that her other child also has
the Coccobacillus H. influenza bacteria. She is concerned. What is your best
response?
a. All of us have bacteria in our bodies called flora. Flora isn’t harmful and is sometimes
helpful. The bacteria that caused your child’s infection are flora; however, your
child’s recent viral infection weakened your child’s immune system enabling these
bacteria to cause the infection.
b. All of us have bacteria in our bodies called flora. Flora isn’t harmful and is sometimes
helpful. The bacteria that caused your child’s infection are flora; however, your
child’s recent viral infection weakened your child’s immune system enabling these
bacteria to cause the infection. Your other child didn’t come down with the viral
infection and therefore won’t get this bacterial infection.
c. All of us have bacteria in our bodies called flora. Flora isn’t harmful and is sometimes
helpful. The bacteria that caused your child’s infection are flora; however, your
child’s recent bacterial infection weakened your child’s immune system enabling
these bacteria to cause the infection. Your other child didn’t come down with the
viral infection and therefore didn’t get this bacterial infection; however, you should
talk to your health-care provider to determine if your child should be vaccinated
against these bacteria.
Answer:
Signs and Symptoms
䊋 Nasal congestion
䊋 Nonproductive cough
䊋 Sneezing
䊋 Watery eyes
䊋 Low-grade fever
䊋 Severe, irritable coughing spasms
䊋 Whooping sound on inspiration
Test Results
䊋 Culture and sensitive test: Identified B. pertussis, B. parapertussis, or
B. bronchiseptica
Treatment
䊋 Administer erythromycin for 14 days to kill the bacteria.
䊋 Administer erythromycin prophylatically to others who have been in
close contact with the patient.
Nursing alert Administer cotrimoxazole (Bactrim) if the child is unable to tolerate
erythromycin.
Nursing Intervention
䊋 Provide droplet isolation immediately.
䊋 Everyone must wear gowns, masks, and gloves when in contact with the
patient.
䊋 Provide a quiet environment to avoid stimulants that might lead to coughing.
䊋 Report the diagnoses to local health officials according to policy.
䊋 Explain the disorder and treatment to the family and to the patient.
Nursing alert Isolation precautions remain in effect until after day 7 of antibiotic
treatment.
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1. A father brought his 7-year-old son to the ED complaining that his son was achy and
has a slight fever and headaches. He said he was fine 4 weeks ago when they spent time
in the family’s woodland cabin. What is your best response?
a. Look for a bull’s-eye rash.
b. Tell the father that the health-care provider will probably perform tests to determine
if his son has Lyme disease.
c. Tell the father that the son probably caught a cold and it will resolve within 10 days.
d. Place the child in isolation immediately.
Answer:
✔ ROUTINE CHECKUP 2
TETANUS
What Went Wrong?
Tetanus is a bacterial infection caused by the Clostridium tetani bacteria when
the bacteria enters the body through an opening in the skin, causing muscles
to tighten and become rigid especially in the mouth, making it difficult to
breath and swallow. The incubation period can be up to 14 days before symp-
toms appear. The child should receive immunization to tetanus as part of the
DTaP vaccination beginning at 2 months of age.
Nursing alert The patient is alert and has full mental capacity while infected.
Signs and Symptoms
䊋 Lockjaw
䊋 Stiff neck
䊋 Facial muscle spasms
䊋 Difficulty swallowing (dysphagia)
䊋 Low-grade fever
䊋 Sweating
䊋 Sensitivity to external stimulation
Test Results
䊋 Serum: Normal
Nursing alert Diagnosis is based on symptoms and history and by ruling out
neurologic disorders.
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2. A mother mentioned to you in passing that her daughter’s best friend frequently goes
into a coughing spasm and makes this strange sound after each cough. She thinks it
must be allergies because nothing is coughed up. What is your best response?
a. Has your daughter been vaccinated for whooping cough?
b. Has your daughter’s friend been vaccinated for whooping cough?
c. Have you been vaccinated for whooping cough?
d. Does your daughter have allergies?
Answer:
Treatment
䊋 Administer tetanus immune globulin to reverse tetanus toxin.
䊋 Administer tetanus toxoid at an injection site different from the tetanus
immune globulin.
䊋 Administer antibiotic (penicillin G, metronidazole, erythromycin, tetra-
cycline).
䊋 Administer muscle relaxants.
䊋 Debride the wound.
Nursing Intervention
䊋 Place the patient in the intensive care unit to monitor cardiorespiratory
function.
䊋 Provide a quiet environment to reduce external stimuli.
䊋 Limit touching and moving the patient to reduce external stimuli.
䊋 Explain the disorder and treatment to the family and to the patient,
remembering that the patient has full mental capacity.
Nursing alert Keep rescue equipment nearby because all muscles might become
rigid and disrupt the patient’s cardiorespiratory function.
FIFTH DISEASE
What Went Wrong?
Fifth disease is a viral infection caused by the human parvovirus B19 virus that
is transmitted through infected blood and respiratory droplets. The incubation
period is between 6 and 14 days after symptoms appear. The fifth disease is
the fifth most common rash producing viral infection in children. The others
are rubella, rubeola, roseola infantum, and varicella.
Signs and Symptoms
䊋 Slapped-cheek-like rash on the face.
䊋 Flat red spotted rash on the trunk and proximal extremities. The rash
fades in the center of the rash.
䊋 No rash on the palms and soles.
䊋 Upper respiratory infection.
䊋 Low-grade fever.
䊋 Headache.
Test Results
䊋 No tests
Nursing alert Diagnosis is based on symptoms, history, and by ruling out other
disorders.
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