Pediatric nursing ch 22 Flashcards
Nurses should be aware of the following considerations when it comes to administering immunizations.
Some immunizations may cause mild fever, or soreness and redness at the injection site. Teach parents how to calculate appropriate doses of acetaminophen to relieve pain or fever after the immunization. Discuss with parents that acetaminophen (Tylenol) or ibuprofen is not needed unless the child is uncomfortable from the fever or pain. These medications are no longer recommended because of potential to decrease immune reaction to vaccine (Wysocki et al., 2017). Warm compresses may also be applied to the injection site.
Children with mild cold symptoms may receive immunizations. However, if they are moderately to severely ill with or without fever, it is better to hold the immunization until later (CDC, 2017b).
Legal caregivers must receive a vaccine information statement (VIS) that explains the purpose of the vaccine, possible side effects, and how to care for the child. This statement also informs and questions the caregiver about possible contraindications and allergies to the vaccine. Caregivers must sign a permission form before the child receives the immunization.
VIS forms can be obtained in many languages.
All adverse effects of immunizations must be reported. The physician or nurse practitioner may file a Vaccine Adverse Event Report with the Centers for Disease Control and Prevention (CDC, 2017d).
Documentation must include the lot number of the vaccine. The lot number is recorded on the vaccine label. Documentation also includes the route and site of vaccine administration and the date that the vaccine was given. Copies of permission forms must be kept on file (CDC, 2015a), as well as the manufacturer and source of the vaccine and the date of the VIS form.
Immunizations From Birth to Age 18 Years
Immunizations for children from birth to age 18 years are described by the CDC (2017a) as detailed in Fig. 22–1.
A mild illness is not considered a contraindication to receiving vaccines. Contraindications for each vaccine include a previous severe allergic reaction to any component of the vaccine.
Hepatitis B
The hepatitis B vaccine is administered to all newborns. If the mother is positive for hepatitis B surface antigen (HBsAg), 0.5 mL of hepatitis B immune globulin (HBIG) is also given.
Three doses of hepatitis B are given before age 2 years: at birth, at 1 to 2 months of age, and at 9 to 12 months of age.
If a dose is missed, the series does not have to be restarted. It should be continued.
A specific contraindication to hepatitis B is a hypersensitivity to yeast (CDC, 2017b).
Hepatitis A
The hepatitis A vaccine is given to all children 12 months and older.
This vaccine is especially important in children who are traveling or who are otherwise at risk for the disease.
The hepatitis A vaccine is not given before 12 months of age.
Two doses are given, at least 6 to 18 months apart.
Diphtheria, Tetanus, Pertussis/DT
Four doses are given for infants and toddlers: at 2, 4, 6, and 15 to 18 months.
A final dose in the series is given between age 4 and 6 years.
The diphtheria, tetanus, pertussis (DTaP) vaccine may cause irritability, loss of appetite, and localized swelling and tenderness at the injection site. Seizures are a rare side effect of the DTaP due to the pertussis component of the vaccine. However, this vaccine is much safer now because only acellular components are used to manufacture the vaccine.
DT is for children younger than 7 years who cannot have the pertussis component of the DTaP vaccine.
Haemophilus influenzae Type B
Haemophilus influenzae type B (Hib) is a bacterium that causes infection in various parts of the body.
This organism was at one time a leading cause of meningitis in young children, and is a significant cause of conjunctivitis, otitis media, and sinusitis.
The Hib vaccine is given in a series of four doses: at 2, 4, 6, and 12 to 15 months. No additional doses are given after this series.
Rotavirus
Rotavirus is a live attenuated vaccine.
Rotavirus causes severe diarrhea and dehydration.
Two vaccinations are available for rotavirus. Based on vaccine use, dosing schedules vary.
The first immunization is given between 6 and 14 weeks. The series is not started if the infant is more than 14 weeks and 6 days.
Three doses of RotaTeq vaccination are given orally at 2, 4, and 6 months.
If Rotarix is given at 2 and 4 months, no additional doses are given.
Avoid immunization if the child has a history of intussusception, other gastrointestinal disorder, or severe combined immunodeficiency.
Pneumococcal (PCV13 and PPSV23)
The pneumococcal conjugate vaccine (PCV13) is recommended for children younger than 5 years to protect against Streptococcus pneumoniae (pneumococcus).
PCV13 replaces PCV7. A single additional dose of PCV13 is recommended for all children 14 to 59 months who have received an age-appropriate series of PCV7 and for all children 60 to 71 months with underlying specific medical conditions who have received an age-appropriate series of PCV7.
Four doses of PCV13 are given in the series: at 2, 4, 6, and 12 to 15 months.
The pneumococcal polysaccharide vaccine (PPSV23) is used for older children and adults, but may be used in children older than 2 years who have special medical conditions such as a cochlear implant or are asplenic from sickle cell anemia.
The pneumococcal vaccine protects children from meningitis, otitis media, and other infections.
Inactivated Poliovirus
Inactivated poliovirus vaccine (IPV) has replaced the live, oral vaccine (OPV) in the United States. IPV is safer to use because OPV contains live viruses and may cause paralysis in immunodeficient children or in close contacts who are immunodeficient.
IPV is given in a series of four doses: at 2, 4, and 6 to 18 months, and 4 to 6 years.
Influenza
Children aged 6 months to 18 years should receive an influenza immunization annually.
Children through 8 years of age who are receiving their first influenza immunization need two doses, at least 4 weeks apart.
Children older than 2 years have the option of receiving a live, attenuated influenza virus through a nasal spray as an alternative to the injection. However, after recent studies have shown it was less effective during the flu seasons from 2013 to 2016, the CDC did not recommend it for the 2016 to 2017 influenza season (Grohskopf et al., 2016). It is unclear whether this recommendation will persist.
If used, the nasal spray vaccine is contraindicated for children with asthma and should not be given to children aged 2 to 4 years who have been wheezing within the past 12 months.
The influenza nasal spray may cause symptoms of mild flu because it is manufactured from a weakened form of the live virus.
The influenza immunization is contraindicated for individuals who are allergic to previous doses of influenza. Caution should be used in those allergic to eggs or egg products, or those who have moderate to severe acute illness. Hives secondary to egg allergy are not considered a contraindication.
Measles, Mumps, Rubella
The minimum age for receiving this immunization is 12 months. Do not give before the first birthday unless traveling outside the United States, in which case the child will need to still receive two doses of vaccine per regular schedule.
The second dose is generally given at 4 to 6 years of age but may be given before age 4 years if at least 4 weeks have elapsed since the first dose.
Children may experience maculopapular rash, fever, swollen cheeks, and mild joint pain after receiving the MMR vaccine.
MMR is contraindicated for persons who are allergic to vaccine components, are pregnant, have immunodeficiency, or have a family history of altered immunocompetence. Caution should be used if the patient is a recent recipient of antibody-containing blood products, intravenous gamma globulin, has a history of thrombocytopenia, has the need for tuberculosis (TB) skin test or IGRA (interferon-gamma release assay) testing, and those with moderate-to-severe acute illness. The TB test may be given before or at the same time as the MMR vaccine or 28 days later.
The MMR vaccine may be given to a child who is HIV positive as long as he or she is not severely immunocompromised.
Varicella (Varivax)
Varicella is a live attenuated virus vaccine.
The minimum age for receiving this immunization is 12 months. Do not give before the first birthday.
The second dose is generally given at 4 to 6 years of age but may be given before age 4 years if at least 3 months have lapsed since the first dose.
Negative side effects include erythema and soreness at the injection site. A few people may experience a varicella-type rash at the injection site.
Varicella vaccine is contraindicated for persons who are allergic to components of vaccines or have had previous severe allergic reaction to the vaccines, those with severe immunodeficiency, those who are pregnant, or those with a family history of altered immunocompetence. Caution should be used in those with recent antibody-containing blood products or with moderate-to-severe acute illness.
The vaccine should not be given if antiviral drugs have been given in the previous 24 hours, and antiviral drugs should be avoided 14 days after the varicella immunization (CDC, 2017b).
If a child is taking aspirin for another condition such as Kawasaki disease, then the parents/caregivers should be educated about the signs and symptoms of Reye syndrome.
Meningococcal (Menactra or Menveo)
The meningococcal vaccine is given at 11 to 12 years of age with a booster at 16 years of age. Meningococcal conjugate ACWY is given to children who are 2 to 18 years of age and are at high risk due to asplenia, immunodeficiency disorders, or HIV, or who live in or travel to a country where meningococcal disease is an epidemic (CDC, 2017b).
Avoid the immunization if the child was allergic to a previous dose or component of vaccine. Use caution in children who have moderate-to-severe acute illness.
Meningococcal Serogroup B Vaccine (MenB-FHbp or MenB-4C)
The meningococcal serogroup B vaccine is recommended for individuals at age 10 and at age 25 years who are at risk for meningitis serogroup B. Increased risks include persistent complement component deficiencies, those with functional or anatomic asplenia, or routine exposure to these diseases. The vaccine can also be given to healthy individuals 16 to 23 years of age for short-term protection against the most common strains of meningococcal disease.
Two vaccines are licensed in the United States and the vaccines are not interchangeable. When a person starts a dosing series with one type of vaccine, all doses must be completed with the same vaccine type.
Persons who are at high risk should receive the vaccine in a three-dose series with vaccine spacing of 1 to 2 months following initial vaccine for second vaccine and 6 months for the third dose of the vaccine.
Persons who are healthy should receive the vaccine in a two-dose series with 6 months spacing between initial and second dose of vaccine.
It is contraindicated in pregnant/lactating women or in those who have had a severe allergic reaction to the vaccine or any part of the vaccine including latex
Tetanus, Diphtheria, and Acellular Pertussis
Due to waning immunity to pertussis, it is now recommended that all children 11 to 12 years of age receive one dose of tetanus, diphtheria, and acellular pertussis (Tdap) in place of previous Td.
All pregnant adolescents/women should receive a dose of Tdap during each pregnancy (ideally 27 to 36 weeks’ gestation) regardless of time since previous vaccine (CDC, 2017a).
Tdap is contraindicated in patients who have had a severe allergic reaction to the vaccine or its components, or who had encephalopathy within 7 days of previous vaccine. Caution should be used in those who have unstable neurological conditions, history of Arthus-type hypersensitivity reactions after previous dose, or moderate-to-severe acute illness
Human Papillomavirus (HPV-Gardasil)
The human papillomavirus (HPV) vaccine prevents the most common causes of genital warts and helps prevent cervical, anal, oral, and penile cancers.
It is recommended to be given at 11 to 12 years of age (minimum age is 9 years) in a two-dose series with a minimum of 6 months between dosing.
If vaccination is not begun by age 15 years, the patient requires a three-dose series at 0, 1 to 2 months, and 6 months.
The most common side effect of immunization is syncope. Patients should be encouraged to sit for a few minutes after the dose is given and should be warned of this side effect (CDC, 2017a).
HPV is contraindicated in those with a severe allergic reaction to the vaccine or its components, and caution should be used in those who are pregnant or have moderate-to-severe acute illness
Immunization Success
Vaccines have significantly reduced the incidence of many communicable diseases. since widespread vaccination in the United States, only two cases of diphtheria have been reported since 2004. Similarly, polio affected thousands of children until the 1950s, when vaccinations became widespread. Today, the disease has been eliminated from most of the world but is still endemic in several countries worldwide. With the anti-vaccine movement, previously vaccine-preventable diseases such as measles have recurred. Significant outbreaks are reported in areas of poor vaccination, including more than 1,100 cases in 2017. Continued vaccination is essential to prevent the loss of individual and herd immunity required to prevent these communicable diseases
Types of immunity
When a person carries antibodies to a disease, he or she has immunity to that disease. There are two types of immunity:
Active immunity
Active immunity is when a person is exposed to the disease organism and makes his or her own antibodies. Active immunity is permanent or long-lasting.
Natural active immunity: a person actually has the infection and is then immune to the disease
Vaccine-induced immunity: active immunity to a disease that comes from being immunized with a killed or weakened form of that disease
Passive immunity
Passive immunity is when a person is given antibodies to a disease. This immunity is temporary and lasts for only a few weeks or months.
Natural passive immunity: antibodies are passed from mother to fetus by way of the placenta
Passive immunity: given through immune globulins to provide immediate protection against a disease
Types of Vaccines
Types of vaccines (antigens that stimulate an immune response):
Inactivated or killed organism (example: inactivated polio virus):
Live attenuated or weakened virus (examples: MMR and the varicella vaccine)
Inactivated or killed organism (example: inactivated polio virus): The virus is disabled and unable to replicate itself, but it still contains enough of the original characteristics that it can stimulate an immune response.
Live attenuated or weakened virus (examples: MMR and the varicella vaccine)
Acellular vaccine (examples: pertussis and Hib):
Acellular vaccine (examples: pertussis and Hib): The vaccine contains fragments of cells that stimulate an immune response but does not contain the whole cell.
Toxoids (examples: tetanus and diphtheria)
Toxoids (examples: tetanus and diphtheria): Toxins produced by the bacteria are inactivated so that they cannot cause harm but can still stimulate an immune response.
Subunit of virus (example: hepatitis B):
Subunit of virus (example: hepatitis B): Small fragments of viral protein are used.
Vaccination and Autism
Concern regarding vaccine safety has been highly publicized in the media, leading to an anti-vaccine movement and lower vaccination rates. One of the largest controversies is the MMR vaccine’s reported link to autism. Despite this report, multiple studies have shown no link to autism related to vaccines or their components. In a systematic review by Maglione et al. (2014), they found strong evidence after review of the literature including more than 66 studies that MMR is not associated with autism. Further, Jain et al. (2015) did a study to identify those with and without older siblings with autism and their rates of autism in association to MMR vaccinations. After searching almost 100,000 charts, they found no association between increased risk for autism with the MMR vaccine even if the older sibling had autism.
To promote adequate vaccination rates, it is important to educate parents and the public regarding the magnitude of evidence of no link between autism and MMR vaccination.
Assessment
Communicable diseases can affect most body systems and have distinct patterns of presentation. The diagnosis and management of the disease will be based on the subjective and objective findings present in the patient. Nurses should complete a thorough history and physical examination to understand the diagnosis and extent of disease process.
Routes of vaccines
IM, IM or subQ, sub Q, oral
Intramuscular vaccines Diphtheria, tetanus, pertussis (DTaP, DT, Tdap, Td) Hib Hepatitis A Hepatitis B HPV Influenza, trivalent inactivated Meningococcal—conjugate PCV Intramuscular or subcutaneous PPSV IPV Subcutaneous MMR Varicella Meningococcal—polysaccharide Oral Rotavirus
Reducing Fear of Immunizations by Developmental Stage
Vaccines and needlestick procedures are a source of significant distress for children and families. It is important for clinicians to understand ways to manage vaccine anxiety. Discuss previous vaccine experiences and educate patients and families on what to expect from the vaccinations. Parental coaching on supportive, honest cues assists in managing their child’s anxiety.
Based on the child’s developmental stage, different comfort measures are more effective:
Infant comfort measures: swaddling, being held by parents with legs exposed, pacifier, feeding, the use of sugary substances to suck on, and distraction objects in older infants
Toddler comfort measures: simple explanations of what to expect, comfort holds by parents or assistant, distraction measures, managing parental anxiety, positive instructions, and positive rewards
School-age comfort measures: more complex preparatory discussions; use of distractions like deep breathing, guided imagery, interactive toys, coaching activities such as counting to the end of procedure, and talking about other things like pets.
General history
History is essential to assessment of the child who may be experiencing a communicable disease. It is important to ask about the following issues:
Exposure to the disease: Has the child been around other children who have the communicable disease? Is the child in close contact with other children at daycare or schools? Have family members been exposed to a communicable disease?
Consider the incubation period of a disease and the length of time it takes for symptoms to appear from the time the child was exposed.
Has the child had any communicable diseases in the past?
What immunizations has the child had? Are immunizations up to date with recommended schedule?
Any child 2 months or younger with a fever of 101°F or higher should be seen by a health-care professional to evaluate for subtle signs of sepsis or other concerning infections. The very young infant does not yet have a fully functioning immune status, and presentations of communicable diseases may be subtle.
Physical Examination
Physical assessment of a child with communicable disease includes assessing prodromal signs and symptoms that may appear before a rash or the main illness appears. The prodromal period is often associated with increased communicability of the disease. Prodromal signs and symptoms may include:
Coryza (runny nose) Cough Fever Malaise General signs and symptoms experienced by a child with communicable disease include:
Changes in behavior—lethargy or irritability
Skin rashes that may itch and may include macules, papules, pustules, and vesicles
Enlarged lymph nodes that may vary in location based on the disease but are predominately located in the anterior cervical, posterior cervical, and tonsillar areas
Fever
Vomiting and diarrhea
Pain in any part of the body, including headache, abdominal pain, throat pain, or muscle aches
VIRAL COMMUNICABLE DISEASES
Viral communicable diseases are some of the most common diseases acquired by humans. Thousands of viruses can result in minor illnesses such as the common cold, as well as more significant diseases such as meningitis. This section highlights common and serious viral diseases in childhood.Table 22-1 page 522
Universal precautions
Universal precautions prevent the transmission of HIV, hepatitis B and C, and other blood-borne pathogens. Universal precautions apply to blood, any body fluids that contain blood, semen, and vaginal discharge. Universal precautions provide guidelines for using protective barriers such as gloves, gowns, masks, and eyewear as needed to protect the health-care worker. Guidelines also prevent injuries from needlesticks and other sharp instruments
Standard precautions
Standard precautions are more comprehensive than universal precautions and apply to all patients in any setting. Major components of standard precautions include careful hand hygiene, safe injection practices, safe handling of contaminated equipment, and appropriate isolation techniques based on possible exposure to pathogens. Isolation techniques may involve gloves only or may call for gowns, masks (droplet precaution), or eye protection (invasive procedures). Standard precautions also protect the patient by preventing spread of pathogens from health-care providers or equipment to the patient
Caregiver Education
Situations with an ill child that require emergency medical services include the following (Randolph & McCulloh, 2014):
Difficulty breathing
Refusal to lie down
Blue, gray, or purple tinge on lips or skin
Fever associated with difficulty breathing or abnormal skin color (pallor, bluish tinge, exceptionally pink)
Fever with headache or stiff neck
Behavior changes such as lethargy, acting withdrawn, or becoming more unresponsive
Seizure activity in a child not known to have seizures and without a plan for managing seizures
Purple or red rash that is spreading quickly, rash that does not blanch (petechiae)
Dehydration accompanied by lethargy, sunken eyes, no tears in an infant older than 2 months, decreased urine output
Vomiting blood, or blood in the stool
Erythema Infectiosum (Fifth Disease)
Erythema infectiosum commonly affects school-age children 5 to 15 years of age. This rash is a self-limited viral infection but can have persistent lacy rash for several weeks after initial infection.
Disease process
Agent: human parvovirus B19 (HPV)
Transmission: contact with respiratory secretions
Incubation period: 4 to 21 days
Communicability: contagious until the rash appears
Precautions: droplet
Clinical Presentation/Diagnostic Testing/Nursing Interventions
Prodromal: fever, upper respiratory symptoms, headache
Rash distribution: erythema of the cheeks, giving the appearance of “slapped cheeks.” The rash appears after the red cheeks appear and is characterized by a lacy pattern on the trunk and extremities. The rash may disappear and then reappear if the child becomes hot for weeks after the infection (Fig. 22–2).
Systemic signs and symptoms: no signs or symptoms after the rash has appeared. In adults, there may be pain and swelling of joints (American Academy of Pediatrics
Blood testing will reveal the presence of immunoglobulin M (IgM) antibody that indicates immunity to parvovirus B19.
Nursing interventions for patients with fifth disease include emergency care and acute hospital care.
Emergency Care
Sickle cell crisis may occur with HPV in susceptible persons.
Acute Hospital Care
Fifth disease may be severe in individuals with immune deficiency disorders.
A child with HPV who is hospitalized with aplastic crisis or because of immunodeficiency must be placed on droplet precautions.
A child in aplastic crisis may not have the typical rash, but complain of fever, nausea and vomiting, abdominal pain, malaise, and lethargy.
The disease may trigger a crisis in persons with sickle cell disease. It may also trigger aplastic crisis in children who are immunodeficient.
Home Care
Acetaminophen or ibuprofen for fever or discomfort; adequate hydration
