Childhood Communicable Diseases, Bioterrorism, Natural Disasters, and the Maternal-Child Patient PDF

Childhood Communicable Diseases, Bioterrorism, Natural Disasters, and the Maternal-Child Patient OBJECTIVES 1. 2. 3. 4. Define each key term listed. Discuss the characteristics of common childhood communicable diseases. Interpret the detection and prevention of common childhood communicable diseases...

Childhood Communicable Diseases, Bioterrorism, Natural Disasters, and the Maternal-Child Patient OBJECTIVES 1. 2. 3. 4. Define each key term listed. Discuss the characteristics of common childhood communicable diseases. Interpret the detection and prevention of common childhood communicable diseases. Discuss three principles involved in Standard and Transmission-Based Precautions used to prevent the transmission of communicable diseases in children. 5. Discuss national immunization programs. 6. Develop an awareness of worldwide efforts to control the spread of communicable diseases. 7. Describe the nurse’s role in the immunization of children. 8. Understand the vulnerability of pregnant women, young infants, and children to exposure to bioterrorism agents. 9. Understand the role of the nurse in the hospital and in the community in preventing and responding to disaster events. 10. Demonstrate a teaching plan for preventing sexually transmitted infections (STIs) in an adolescent. 11. Formulate a nursing care plan for a child with acquired immunodeficiency syndrome (AIDS). KEY TERMS acquired immunity (p. 743) active immunity (p. 743) body substance (p. 742) communicable disease (kŏ-MYŪ-nĭ-kă-būl dĭ-ZĒZ, p. 742) endemic (ĕn-DĔM-ĭk, p. 742) epidemic (ĕp-ĭ-DĔM-ĭk, p. 742) erythema (ĕr-ĭ-THĒ-mă, p. 746) fomite (FŌ-mīt, p. 742) health care–associated infection (p. 742) incubation period (p. 742) macule (MĂK-yūl, p. 746) natural immunity (p. 742) 1416 opportunistic infections (ŏp-pŏr-tū-NĬS-tĭk ĭn-FĔK-shŭnz, p. 742) pandemic (păn-DĔM-ĭk, p. 742) papule (PĂP-yūl, p. 746) passive immunity (p. 743) pathogens (PĂTH-ō-jĕnz, p. 742) pathognomonic (păth-ŏg-nō-MŎN-ĭk, p. 746) portal of entry (p. 742) portal of exit (p. 742) prodromal period (prō-DRŌ-mŭl PĒ-rē-ŏd, p. 742) pustule (PŬS-tyūl, p. 746) reservoir for infection (p. 742) scab (p. 746) Standard Precautions (p. 743) Transmission-Based Precautions (p. 743) vector (VĔK-tŭr, p. 742) vesicle (VĔS-ĭ-kŭl, p. 746) http://evolve.elsevier.com/Leifer 1417 Introduction There have been only a few brief periods in history when infectious disease did not dominate the attention of health care professionals. Despite immunization, sanitation, antimicrobial drugs, and other controls, the world continues to face infectious agents, such as human immunodeficiency virus (HIV), hepatitis, tuberculosis, and sexually transmitted infections (STIs). Despite our knowledge of immunizations, some children still suffer from common communicable diseases. Antimicrobial drug-resistant organisms are increasing in number and virulence, and immunocompromised patients are threatened by nonpathogenic organisms. Prevention and control are key factors in managing infectious disease. 1418 Common childhood communicable diseases The incidence of common childhood communicable diseases has dramatically decreased as immunological agents have been developed. Diseases such as smallpox have declined to a point worldwide that routine immunizations are no longer recommended. (A brief review of smallpox is presented in this chapter, because the nurse must be able to identify a smallpox lesion, promptly isolate the patient, and arrange for immediate follow-up care to prevent an outbreak of this deadly illness.) Providing all children with the appropriate immunizations is the health care challenge of today. Air travel is commonplace, and rapid transmission of contagious diseases from around the world makes alert assessment by the nurse and all health care workers essential. Most viral infections are contagious for 2 to 3 days before the characteristic symptoms occur. Home care is the preferred care setting for children with communicable diseases. In most families, both parents work, and childcare facilities have become the primary day care setting for preschool children. Intimate contact is a routine part of children’s play in childcare settings, so washing hands and a general hygienic environment, in addition to fully immunized children and staff, are essential to minimize the spread of infection. Policies for excluding children who are ill should be well understood by parents and childcare staff. Staff who serve food should not be assigned to change diapers. See the following Healthcare Promotion table for selected recommendations concerning excluding children with communicable disease from childcare facilities or school. Health Promotion Communicable Diseases of Childhood 1419 1420 1421 CNS, Central nervous system; DTaP, diphtheria-tetanus–acellular pertussis vaccine; IGRA, interferon-gamma release assay; MMR, measles-mumps-rubella vaccine; PPD, purified protein derivative; VZIG, varicella-zoster immune globulin. Note: DTaP is administered to infants and children up to age 10 years; Tdap (tetanus-diphtheria–acellular pertussis vaccine) is provided to children age 11 years or older. FIG. 32.1 Chickenpox. (From Feigin RD, Cherry JD: Textbook of pediatric infectious diseases, ed 2, Philadelphia, 1987, Saunders.) 1422 FIG. 32.2 German measles. (From Hurwitz S: Clinical pediatric dermatology: a textbook of skin disorders of childhood and adolescence, ed 5, Philadelphia, 2016, Elsevier.) 1423 FIG. 32.3 Measles. (From Hurwitz S: Clinical pediatric dermatology: a textbook of skin disorders of childhood and adolescence, ed 5, Philadelphia, 2016, Elsevier.) 1424 Review of terms A communicable disease is one that can be transmitted, directly or indirectly, from one person to another. Organisms that cause disease are called pathogens. The incubation period is the time between the invasion by the pathogen and the onset of clinical symptoms. The prodromal period refers to the initial stage of a disease – the interval between the earliest symptoms and the appearance of a typical rash or fever. Children are often contagious during this time, but because the symptoms are not specific, they may attend preschool or another group program and spread the disease. A fomite is any inanimate material that absorbs and transmits infection. A vector is an insect or animal that carries and spreads a disease. A pandemic is a worldwide high incidence of a communicable disease. An epidemic is a sudden increase of a communicable disease in a localized area. Endemic refers to a continuous incidence of a communicable disease expected in a localized area. Body substance refers to moist secretions or parts of the body that can contain microorganisms. Emesis, saliva, sputum, semen, urine, feces, and blood are examples of body substances. Body Substance Precautions indicate the need to wear disposable protective gloves and/or garments when coming in contact with these body substances. A portal of entry is a route by which the organisms enter the body (e.g., a cut in the skin). A portal of exit is the route by which the organisms exit the body (e.g., feces or urine). A reservoir for infection is a place that supports the growth of organisms (e.g., standing, stagnant water). The chain of infection refers to the way organisms spread and infect the individual (Fig. 32.4). Standard Precautions are found in Appendix A. Careful hand hygiene is basic and essential to prevent the spread of infection. 1425 FIG. 32.4 The chain of infection. The process by which pathogens are transmitted from the environment to a host, invade the host, and cause infection. (From Leahy J, Kizilay P: Foundations of nursing practice: a nursing process approach, Philadelphia, 1998, Saunders.) 1426 Host resistance Many factors contribute to the virulence of an infectious disease. The age, sex, and genetic makeup of the child have a bearing on the degree of resistance. The nutritional status of the person and his or her physical and emotional health are also important. The efficiency of the blood-forming organs and of the immune systems affects resistance. Important factors in host resistance to disease include: Intact skin and mucous membranes: A break in the skin can be a portal of entry for an organism that can cause illness. Phagocytes in the blood attack and destroy organisms. The functioning immune system in the body responds to fight infection. Some factors in this immune response include interferon, T cells, B cells, and antibodies. Vaccinations assist the body to manufacture antibodies that can help the child to resist infections. The child who has an underlying condition, such as diabetes, cystic fibrosis, burns, or sickle cell disease, may be more susceptible to certain organisms. Children with HIV or acquired immunodeficiency syndrome (AIDS) or cancer and children receiving steroid or immunosuppressive drugs often have depressed immune systems. This makes them very susceptible to opportunistic infections (an opportunistic infection is caused by organisms normally found in the environment that the immune-suppressed individual cannot resist or fight). An infection acquired in a health care facility during hospitalization is termed a health care–associated infection. Types of immunity Immunity is the natural or acquired resistance to infection. In natural immunity, resistance is inborn. Some races apparently have a greater natural immunity to certain diseases than other races. Immunity also varies from person to person. If two persons are exposed to the same disease, one may become very ill and the other may show no evidence of the disease. Acquired immunity is not the result of inherited factors but is gained as a result of having the disease or is artificially acquired by receiving vaccines or immune serums. Vaccines contain live attenuated (weakened) or dead organisms that are not strong enough to cause the disease but stimulate the body to develop an immune reaction and antibodies. When the person produces his or her own immunity, it is called active immunity. If a person is exposed to and needs immediate protection from a specific infectious disease, antibodies can be obtained in immune serums; most are from animals, but some are from humans. For example, tetanus serum (used to prevent lockjaw) is procured from the horse, but gamma globulin, which is rich in antibodies, is obtained from human blood. This type of immunity, known as passive immunity, acts immediately but does not last as long as immunity actively produced by the body. Passive immunity provides the antibody. It does not stimulate the system to produce its own antibodies. A carrier is a person who is capable of spreading a disease but does not show evidence of it. Typhoid fever is an example of a disease spread by a carrier. Transmission of infection Infection can be transmitted from one person to another by direct or indirect means. Direct transmission involves contact with the person who is infected (the body fluids of that person, such as nasal discharge or an open lesion). Indirect transmission involves contact with objects that have been contaminated by the infected person. These objects are called fomites. Bedrails, intravenous (IV) pumps, overbed tables, door handles, used tissues, countertops, and toys are examples of fomites. For example, the respiratory syncytial virus (RSV) lives on dry soap for several hours. Therefore picking up soap used by a person infected with RSV transmits the organism. This is one of the reasons the use of liquid soap is advocated. The chain of infection transmission is shown in Fig. 32.4. Preventing the spread of infection depends on breaking the chain. 1427 Various tests are available to determine whether an individual has been exposed to a particular disease. For example, tests for tuberculosis infection include the Mantoux intradermal purified protein derivative (PPD) skin test and a blood serum test called the Interferon-Gamma Release Assay (IGRA) (more commonly referred to as either QuantiFERON-TB Gold or T-spot). The Schick test for diphtheria and the Dick test for scarlet fever have been replaced by serum DNA-PCR (DNA polymerase chain reaction) testing. 1428 Medical asepsis, standard precautions, and transmission-based precautions The purpose of medical aseptic techniques used with all patients is to prevent the spread of infection from one person to another. A person or an object is considered contaminated if he, she, or it has touched the infected patient or any equipment or fomite that has come in contact with the patient or his or her bodily fluids. Articles that have come in direct contact with the patient must be disinfected before others can use them. When something is disinfected, the microorganisms in or on it are killed by physical or chemical means. The autoclave, which uses steam under pressure, is considered effective in killing most microbes when the article is adequately exposed and sterilized for the proper length of time. All children suspected of having a communicable disease who are admitted to the hospital are placed on both Standard and Transmission-Based Precautions until a definite diagnosis is established. A private room or negative pressure room (prevents air from flowing out of the room when the door is opened) may be assigned. (See Appendix A for specific Transmission-Based Precautions and the practices required.) Disposable items are used when a child is placed on Transmission-Based Precautions; these include tissues, suction catheters, thermometers, suture sets, nursing bottles, and blood pressure cuffs. They are disposed of according to hospital protocol. The nurse must understand the importance of protecting himself or herself and others from a contagious patient. This is accomplished by specific precautions, called Standard Precautions. The Centers for Disease Control and Prevention (CDC) recommend that Standard Precautions be used for all patients; these involve, at minimum, hand hygiene and the use of disposable gloves. In addition to these precautions, Transmission-Based Precautions are designed according to the method of spread of infection, such as airborne infection isolation, contact, and droplet (see Appendix A). Airborne Infection Isolation (AII) Precautions are used for patients with conditions such as tuberculosis, varicella (chickenpox), and rubeola (measles). Small airborne particles floating in the air can be inhaled anyplace in the room. Negative pressure rooms must be used, and respirator masks (e.g., N95 particulate masks) are required when entering the room. The respirator masks are removed when exiting the room (Table 32.1). Table 32.1 QSEN Interdisciplinary Patient Care Plan 1429 * EHR=Electronic Health Record * MAR=Medication Administration Record * QSEN=Quality and Safety Education for Nurses (QSEN.org) Summary of participants in the multidisciplinary team for care given today related to this nursing diagnosis: Charge nurse Child life specialist 1430 Dietary personnel Engineering department Family Health care provider Infection prevention and control nurse Lab technician Nursing team members Patient Pharmacist Public health department (PHD)–TB control nurse Social worker QSEN is based upon the Institute of Medicine Competencies defined in “Health Profession Education – A Bridge to Quality.” Washington, DC. National Academy Press 2003 and Cronewett L.; Sherwood G; Barnsteiner J (2007). Quality and Safety Education for Nurses. Nursing Outlook 55(3):122–131. Also see Chapter 1 for introduction to QSEN in nursing. Contact Precautions are used when the condition causes organisms to be transmitted via skin-toskin contact or through indirect touch of a contaminated fomite. Gloves and a cover gown are worn for close contact with patients with RSV, patients with hepatitis A who are incontinent, patients with contagious skin diseases (e.g., impetigo), and patients with wound infections. It is important to note that some diseases may have more than one mode of spread and therefore necessitate more than one precaution technique. Droplet Precautions are used with diseases such as pertussis and influenza. When the patient coughs or sneezes, the droplets can contaminate an area 3 feet around the patient. Beyond the 3-foot (0.91 meters) radius, a mask and gown are not usually necessary. Standard Precautions are discussed in Appendix A, along with the protocols for the use of masks, gowns, gloves, and other protective equipment. Personal protective equipment (PPE) should be worn when anticipating the risk of exposure to blood, body fluids, or other potentially infectious materials. Safety Alert! Disposable gloves should be worn whenever touching something that is moist and not yours. Protective environment isolation Protective Environment Isolation Precautions (previously called reverse isolation) are used for patients who are not communicable but have a lowered resistance, perhaps because of neutropenia, and are highly susceptible to infection. This simple procedure reduces the incidence of health care– associated infections. The patient is placed in a private room with the door closed. It is recommended that all persons wear a gown, a mask, and gloves when attending the child. Both the child and family need adequate explanations concerning the protective environment precautions. Hand hygiene The nurse must perform hand hygiene on his or her hands between patients and after removing gloves. Hospital-approved antibacterial soaps and lotions are used. The use of hot water, instead of warm water, can irritate skin and may promote the development of resistant strains of microorganisms. Self-contained liquid soap dispensers are preferable to bar soap that can harbor organisms. Alcohol-based hand sanitizers can be used as long as the hands are not visibly soiled. Artificial fingernails, including tips, wraps, and nail jewelry, are not permitted in patient care areas. Refer to the hospital’s infection prevention and control protocol. Caregivers with skin lesions on exposed areas of their bodies should not provide direct patient care until the lesions are completely cleared. 1431 Safety Alert! Alcohol-based hand sanitizers should not be used when caring for a patient diagnosed with Clostridium difficile diarrhea, because this organism is spore forming and resistant to alcohols. Soap and water must be used after every contact. Nursing Tip Teaching children and their families to wash their hands before meals and after using the toilet, blowing their noses, sneezing, or handling soiled objects is important to minimize the spread of infection and to promote healthy living. Making hand hygiene fun for children can motivate them to wash appropriately for a minimum of 15 seconds. Family education Education of family members must be ongoing. Factors to be emphasized include the necessity for immunization of children, proper storage of food (particularly perishables), use of pasteurized milk, proper cooking of meats, cleanliness in food preparation, and proper hand hygiene. The nurse must review the ways in which infectious diseases are spread. Children must be taught to avoid using community hand towels. Other modes of transmission, such as crowded living conditions, insects, rodents, and sandboxes, may also be discussed. 1432 Rashes Many infectious diseases begin with a rash. Rashes tend to be itchy (pruritic) and uncomfortable. Symptomatic care is provided by prescribing acetaminophen (Tylenol) and diphenhydramine (Benadryl), or topical lotions. Rashes can be described as follows (see Box 30.1): Erythema: Diffused reddened area on the skin Macule: Circular reddened area on the skin Papule: Circular reddened area on the skin that is elevated Vesicle: Circular reddened area on the skin that is elevated and contains fluid Pustule: Circular reddened area on the skin that is elevated and contains pus Scab: Dried pustule that is covered with a crust Pathognomonic: Term used to describe a lesion or symptom that is characteristic of a specific illness (e.g., Koplik spots are pathognomonic for measles) Safety Alert! Apply lotions to open lesions sparingly to prevent absorption that could lead to drug toxicity. Worldwide travel makes it a priority for the nurse to be able to communicate with patients in different languages concerning signs and symptoms that may indicate the presence of a communicable disease. Appendix F is an example of a multilingual list of common symptoms related to communicable diseases that can be used by health care personnel. 1433 Worldwide immunization programs Healthy people 2030 Federally funded programs to provide vaccines and to educate are already in place. The efforts of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have resulted in dramatic declines in vaccine-preventable illnesses worldwide, especially in developing countries. New vaccines are developed and assessed for routine use in endemic areas. At a meeting in Switzerland in 2016, the Strategic Advisory Group of Experts (SAGE) discussed immunization practices around the world and produced recommendations and guidelines that were endorsed by WHO and the American Academy of Pediatrics (AAP). Recommendations included the development of a global vaccine action plan; identification of regional challenges; establishment of a storage stockpile for vaccines; and universal access to vaccines. Research priorities also were recommended. Table 32.2 presents types of immunization agents. The influenza vaccine, the pneumococcal vaccine, the varicella vaccine, and RSV immune globulin (RespiGam) are available for children. Vaccines for cholera and yellow fever are available for families traveling to endemic areas. The CDC provides advice concerning vaccinations needed for persons traveling to various parts of the world. Table 32.2 Types of Immunization Agents AGENT Vaccine Toxoid Immune globulin Specific immune globulins or antitoxins DESCRIPTION A suspension of weakened or inactivated (killed) organisms that stimulate immune bodies to form A form of active immunity A modified toxin that stimulates the production of antitoxin A form of active immunity A solution containing antibodies extracted from human or animal blood Provides passive immunity Special preparations obtained from blood donors selected for their high antibody level against a specific disease Provides passive immunity to the specific disease The nurse’s role Worldwide immunization practices have eliminated smallpox as a threat. However, nurses must remain alert to signs and symptoms of communicable diseases, including smallpox. The threat of bioterrorism increases the risk of these and other diseases reemerging. Measles is rarely seen in developed countries. Current vaccinations against varicella, hepatitis, influenza (for children 6 months of age or older and high-risk children), and pneumonia (for children greater than 2 years of age) are available, and the challenge is to make them accessible. The nurse is a vital link in educating parents about the need for immunizations. The U.S. Public Health Service has forms listing the benefits and risks of immunizations that are available to aid in parent education. Parental consent is required before a child is vaccinated, and appropriate Vaccine Information Statements (VISs) should be provided and reviewed with the parents before administration of the vaccine. Vaccines In newborn infants, the presence of passively acquired immunity from the mother may inhibit the infant’s natural immune response to vaccines. Therefore routine immunizations are not started until 2 months of age, unless a high risk of infection exists. Because hepatitis B is a continuing problem in the United States, the immunization series for hepatitis B is often started before the newborn is discharged to the home. Most antibodies cannot reach intracellular sites of infection but can prevent spread from the site of entry into the body to a target organ. For that reason, vaccinations prevent the disease, but most cannot be used to treat the disease after cellular penetration of the organism has occurred. For some diseases, postexposure immunization is recommended; immune globulins are most often the choice. 1434 Multiple doses of a vaccine at predetermined intervals may be needed to achieve an immunity status. The nurse can educate parents and school personnel about immunization schedules and should assess the immunization status of each child at every clinic visit (Fig. 32.5). FIG. 32.5 The “hug” restraining position for administration of vaccinations. Note that the mother restrains the arms, and the child’s legs are restrained between the mother’s knees. The mother comforts the child during the procedure and may breastfeed after the procedure. The site for intramuscular injections in infants is the thigh, and the nurse wears a protective glove. The use of aerosol sprays, EMLA cream, or distraction techniques may reduce the pain of multiple injections in infants and children. Routes of Administration The correct route of administration is important to achieve immunization. The oral, subcutaneous, and intramuscular routes are used for various vaccines. The route of administration of a vaccine influences the response of the infant. The recommended route must be used to obtain optimum response. For example, administration of hepatitis B vaccine into the buttock will not result in the same optimal level of immunity as administration of the vaccine into the deltoid muscle. Refer to Chapter 22 for principles and techniques if administering intramuscular injections to pediatric patients. 1435 Nursing Tip The earliest age at which a vaccine should be administered is the youngest age at which the infant can respond by developing antibodies to that illness. Storage and Handling Correct storage of vaccines is essential to ensure their potency. The nurse should check the label or package insert to determine what type of storage or refrigeration is needed. Improper temperatures can reduce the potency of the vaccine, and there are often no visible signs of these changes. Vaccines should not be stored in the doors of refrigerators or freezers, near the cold air vents in the refrigerator, or in storage bins; they must be placed in the center of shelves to allow the free flow of air around the vaccines. Most vaccines are stored inside the refrigerator at 2° to 8° C (36° to 46° F). Vaccines such as Varivax, HZV, MMR. and MMRV are very fragile; they must be stored in the freezer at − 50° to − 15° C (− 58° to 5° F) and used within 30 minutes of reconstitution. The vaccines cannot be refrozen after they have been thawed. Inactivated vaccines can be harmed if frozen, and live vaccines are harmed by heat and light. This information is especially important to know when participating in outdoor mass immunization programs. In clinic or office settings, the refrigerator temperatures must be documented at the beginning and the end of each workday, and the records must be kept on file for at least 3 years. Refrigerator-freezers with automatic defrost cycles are not appropriate for vaccine storage because temperatures may not be held stable as required. The refrigerator should contain only vaccines, and water bottles should be placed in the refrigerator doors and compartments to help maintain a stable temperature. Manufacturer-filled syringes should remain in the original package until ready for use to protect from exposure to light. The vaccine label or insert will show a “beyond use date” (BUD) for a multidose container. Vaccines predrawn from a vial cannot be reinserted into a multidose vial and must be discarded if not used. The nurse should be aware of backup storage procedures if a power failure occurs. A vaccine handling tool kit and video with updating information about vaccine handling is available at the website https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. Safety Alert! Immune globulin, blood products, and immunosuppressive agents must not be given at the same time as live virus vaccines. Safety Alert! Two to 4 weeks should separate the administration of an inactivated vaccine and a live virus vaccine and 4 weeks before immunosuppressive therapy. Safety Alert! A child who has received immunoglobulin should not be given a live virus vaccine for at least 11 1436 months, so the immunization schedule may need to be revised for that child for the vaccination to be effective. Allergies and Thimerosal Content If a child has a history of allergy, the health care provider should be notified before the child receives any vaccinations. Some multidose containers of vaccines have a latex cover that must be penetrated by the needle; these should be used with caution with individuals who may have a latex allergy. Epinephrine should be available in the unit where vaccines are administered, and the child should be observed for a minimum of 20 minutes before he or she leaves the area. Thimerosal is a mercury-containing preservative used to prevent fungal and bacterial contamination of vaccines in multidose containers. The use of thimerosal as a preservative has decreased since the introduction and widespread use of single-dose vials for vaccinations. All vaccines for pregnant women and children under 6 years of age are available in thimerosal-free vials, and they are also available for adolescents and adults. The FDA has found no evidence of harm from the use of thimerosal in multidose vials of vaccines (http://FDA.org). The detailed content of vaccines can be accessed at the website http://www.know-vaccines.org/?page_id-309. Medication Safety Alert! Varicella vaccine, if not given on the same day as MMR, must be given no less than 28 days later. A tuberculin test should not be administered within 6 weeks of receiving an MMR or varicella immunization, because the results will not be accurate. Refusal of Vaccination When a parent refuses immunizations for their child, the nurse should listen carefully for the reason and offer appropriate education. Some vaccines may contain heavy metals, antibiotics, or animal products. Animal products in a vaccine may present a problem for parents with specific cultural beliefs. The nurse should be culturally sensitive and offer education concerning the value of the vaccine, in addition to options. A list of ingredients found in vaccines can be accessed at the website https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf Nursing Tip Some vaccines contain heavy metals, antibiotics, or animal products, which may be a problem for parents with specific cultural beliefs. Nursing Responsibilities in Vaccine Administration The nurse must be aware of when vaccines are due to be scheduled for administration, the immunization history of the child, the vaccines that can be given together, contraindications, the route of administration, and the proper equipment needed. Epinephrine should be on hand for emergencies, and the child should remain in the clinic under observation for at least 20 minutes. Serious adverse events occurring within a designated time after vaccination should be reported to the national Vaccine Adverse Events Reporting System (VAERS) (https://vaers.hhs.gov) or by calling 1-800-822-7967. The National Childhood Vaccine Injury Act of 1986 contains a provision for compensation in some cases of specific vaccine injuries. All patients should be directly observed for 15 to 20 minutes after receiving an immunization, and appropriate equipment for the treatment of anaphylaxis should be immediately available. Reducing pain at the site of injection, especially when multiple injections are required, should be considered. The use of vapocoolant sprays or EMLA cream (see Fig. 21.3) is effective. Using the 1437 proper injection technique for vaccines is important. The Haemophilus influenzae type b (Hib) vaccine must be dispensed in a separate syringe from other vaccines administered at the same clinic visit. The varicella vaccine is given subcutaneously, whereas the diphtheria-tetanus–acellular pertussis (DTaP) vaccine causes significant tissue irritation if given subcutaneously, and careful intramuscular (IM) technique is essential. Combination vaccines have been developed that reduce the number of injections required at each clinic visit. The CDC and the AAP approve the recommended immunization program in the United States. Advances in the field of immunology may change recommendations for existing policies and cause new policies to be developed (see the sites listed under Online Resources, at the end of the chapter, for updates). Alternative methods of vaccine delivery are being developed, including use of the intranasal route and transdermal techniques. Before a vaccine is administered to a child, the nurse should provide a VIS to the parent, discuss the vaccine, and obtain consent. VISs are printed in several different languages and can easily be obtained online (see Online Resources). Nursing Tip There should be a 3- to 11-month interval between the administration of an immune globulin and administration of a live virus vaccine. Immunization schedule for children Informed consent on the potential risks of vaccination and documentation of the immunization are essential. Parents should have copies of their child’s immunization records. The immunization program for children in the United States is described in Fig. 32.6. 1438 1439 1440 1441 FIG. 32.6 (A) Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. (B) Recommended immunization schedule for persons aged 0 through 18 years - United States, 2018. The Hib vaccine is given intramuscularly. The MMR vaccine and the IPV are given subcutaneously. (C) Catch-up immunization schedule for children 4 months to 18 years who start late or who are more than 1 month behind schedule - United States. DTaP/Tdap, Diphtheria toxoids, pertussis, and tetanus and tetanus-diphtheria-acellular pertussis vaccine; HepB, hepatitis B vaccine; Hep, hepatitis; Hib, Haemophilus influenzae type b vaccine; IPV, inactivated poliovirus vaccine; MMR, measlesmumps-rubella vaccine. (D) Vaccines that might be indicated for children and adolescents aged 18 years or younger based on medical indications. Contraindications to live virus vaccine administration may include: Immunocompromised state (necessitates individual evaluation by the health care provider) Pregnancy Bacteremia or meningitis Immunocompromised caregiver in the home (necessitates individual evaluation by the health care provider) Corticosteroid therapy or immunosuppressive drugs (necessitates individual evaluation) History of high fever (40.5° C [105° F]) after previous vaccinations A subcutaneous injection should be administered with a ⅝-inch, 23- to 25-gauge needle; an IM injection should be administered with a 1- to ¼-inch, 22- to 25-gauge needle; and an intradermal injection should be administered with a ¼- to ½-inch, 25- to 27-gauge needle with the bevel up and parallel to the volar surface of the forearm. Children from 4 months to 18 years of age who start the immunization process late or are more than 1 month behind should adhere to the catch-up schedule (see Fig. 32.6). Nursing Tip 1442 An interrupted vaccination series can usually continue without restarting the entire series. Safety Alert! If the MMR and the Varivax vaccines are not administered on the same day, they must be spaced at least 28 days apart. Purified protein derivative (PPD), a skin test for TB, may be given the same day as the MMR or must be administered at least 4 to 6 weeks later. 1443 The future of immunotherapy Research concerning the development of new vaccines and the refinement of established vaccines continues at an amazing pace. The use of transgenic plants for oral administration of bacterial and viral antigens would enable low-cost, effective distribution. Research in the field of transcutaneous immunization involves the application of an antigen with an adjuvant to the intact skin. Recombinant DNA technology and the use of adjuvants are being developed for rheumatic fever and malaria. Alum is an adjuvant currently used in the vaccine against hepatitis B to increase its effectiveness. Ribonucleic acid (RNA) and DNA viruses are being developed for use as carriers (vectors) of other antigens. Forms of bacterial DNA are also being developed as carriers of antigens. A “gene gun” that blasts the vaccine through intact skin is also in the development stage. The techniques in research may hold promise for developing effective vaccines against influenza A virus, HIV type 1 (HIV-1), malaria organisms, and the Ebola virus. A catalogue of genes that code for viruses and potential immunogens is being studied. The most exciting development in immunology is the use of immunotherapy for noncommunicable diseases. An example would be the mucosal administration of myelin in multiple sclerosis and a type 2 collagen for rheumatic arthritis. The possibility of preventing specific types of cancer has been recognized, and the development of tumor antigens that lyse tumor cells is also a clear possibility. In Alzheimer’s disease, the formation of neurotoxic plaques in the brain causes the loss of mental function. Early immunization with amyloid B may prevent or lyse the plaque formation and prevent the devastating problems of this disease. The use of immunotherapy for autoimmune diseases is promising. The greatest achievement of the 20th century was the eradication of smallpox and the development of many safe vaccines for children. Perhaps the achievement of the 21st century will be the development of immunotherapy for noncommunicable diseases such as Alzheimer’s disease and cancer. 1444 Bioterrorism and the maternal-child patient The nurse’s role in the hospital setting All nurses play a key role in assuring a coordinated and efficient response to natural and humancreated disasters. Whether it is a summer tornado, a winter ice storm, an earthquake, or a terrorist attack, all nurses must have a basic knowledge of what to do. Safety Alert! Although the United States has a response plan for identified incidences of bioterrorism, the nurse should maintain a high level of suspicion when many children with the same signs and symptoms present in school or seek care in a health care facility, and the nurse should call attention to that observation. A basic knowledge of symptoms of exposure and infection, the medical supplies that may be needed, the drugs that may be used, and self-protection that may be essential is important for all nurses at all levels of care, so they can work effectively within a health care team in a time of emergency or disasters. Box 32.1 presents details of the nurse’s role in maternal-child units during a disaster. Box 32.1 The Nurse’s Role During a Disaster in the MaternalChild Units 1. Have a disaster plan in place and know where to find it; know who the leader on the unit is; have protective gear available to wear. 2. The Federal Emergency Management Agency (FEMA) and the Occupational Safety and Health Administration (OSHA) have publications available to help design a plan. The National Incident Management System (NIMS) also has training for disaster events. All nurses should participate in training sessions on a regular basis. 3. Maintain communication with the hospital and community. Everyone should wear a picture ID. 4. Know where emergency outlets are located; they should be clearly marked for use with a generator for priority equipment. 5. Have bag-valve self-inflating masks, in addition to oxygen cylinders and regulators, available on the unit. 6. Provide for gravity-assisted intravenous (IV) and enteral feedings. 7. Use available daylight and have flashlights with batteries available on a crash cart. 8. Document on paper forms until computers are working. 9. Have extra blankets on hand – use kangaroo care for infants as needed. 10. Use manual override for electronic medical dispensing systems. 11. Have a minimum supply of formulas on hand for infants. 12. Have a supply of waterless hand cleaners, diapers, bottles, and nipples. 13. Be sure each infant has proper ID bands, or secure identifying information on Tegaderm and paste to infant’s back during evacuations. 14. Keep patients away from windows. 15. Keep parents and infants together whenever possible. 16. Identify safe areas within the unit for babies, parents, and staff. 1445 Physiological Effects of Biological Agents on Infants and Children Children are generally more vulnerable to biological warfare, because their immune systems are not fully developed. They are also closer to the ground, so heavy particles from an aerosol-propelled agent may reach them in higher doses than a taller adult. All new drugs are tested on adults as they are developed, and it sometimes takes many years to determine the drug’s safety for the pediatric patient. Therefore a new drug that is developed to treat a bioterror or chemical agent may in reality be more harmful than beneficial to the pediatric patient. The large head and body surface area in relation to weight and the low body fat content make the child more vulnerable to developing hypothermia, which can be life-threatening in the pediatric age group. Therefore the routine “hazmat” decontamination procedure of stripping and total body washing may not be suitable for the pediatric patient. The thin skin of the pediatric patient may make dermal chemicals, such as mustard gas, more dangerous to children than adults. A relatively small blood volume makes children more susceptible to fluid losses caused by cholera or other gastrointestinal toxins. Smallpox vaccine cannot be given to pregnant women, and other vaccines, such as anthrax, may not be useful for children. Gas masks are often not available in pediatric sizes, and the national disaster medical system protocol may not make provisions for pediatric beds. Table 32.3 lists common diseases (and their symptoms) that can be spread through bioterrorism. Chemical agents that may be used in a terrorist attack may include pulmonary agents, such as chlorine; cyanide agents, such as sulfur mustard; nerve agents, such as sarin; and incapacitating agents, such as the military glycolate anticholinergic compound coded BZ by the North Atlantic Treaty Organization (NATO). The local health department’s bioterrorism branch should be contacted concerning the management of victims. Table 32.3 Common Diseases/Response to Agents That Can Be Spread Through Bioterrorism AGENT Anthrax SYMPTOMS AND MANAGEMENT Flulike symptoms that improve, after which respiratory and circulatory collapse occur; chest x-ray film shows widened mediastinum caused by thoracic edema; skin lesions involve vesicles with a black eschar center and enlarged adjacent lymph nodes. Management includes ciprofloxacin or doxycycline (ciprofloxacin should be avoided in pregnant women). Vaccine approved for age older than 18 years. Botulism Difficulty speaking and swallowing, blurred or double vision, respiratory distress; descending muscular paralysis. Note: Inhaled form has no gastrointestinal symptoms. Management – Intravenous equine antitoxins and diphenhydramine for serum sickness. Ebola virus Abrupt onset of fever, headache, muscle pain, gastrointestinal upset, maculopapular rash on the (Filovirus) trunk, petechiae, and progressive bleeding. Management – Supportive care. Ribavirin used outside the United States. Lassa fever Fever, retrosternal pain, tremor of tongue and hands, hearing loss. (Arenavirus) Plague Fever, mucopurulent sputum, chest pain, hemoptysis, purpura. Management – gentamycin, streptomycin; ciprofloxacin. Smallpox Chickenpox–like lesions starting on the face and extremities, with each stage of the lesions progressing from one state to the next. Management – Vaccine can be effective if administered 2–3 days after exposure. Vaccine not safe during pregnancy. Tularemia Fever, pneumonitis, nonproductive cough, periorbital edema. Management – Streptomycin, gentamicin, ciprofloxacin, and supportive care. Does not require isolation. Nerve Copious secretions; altered mental status; paralysis agents – Respiratory arrest – Nurses need to wear self-contained breathing apparatus and full protective sarin gear. Respiratory Hives on skin; tearing; blindness; respiratory distress. agents – Smells like newly mowed hay. Agent is heavier than air, therefore ambulatory children may phosgene receive higher exposure. Nurses must wear full protective gear. Vesicants Photophobia; sunburnlike rash. Agent is heavier than air, therefore ambulatory children may be Mustard exposed to larger dose. gas Nurses must wear full protective gear. INCUBATION PERIOD 1–14 days 1–5 days 4–10 days 7–16 days 2–3 days 12 days (average) 3–5 days Decontaminate with soap and water. Atropine preparation administered. Decontaminate. Supportive care. Decontaminate with soap and water. Flush eyes. Treat similar to burns. Provide respiratory support. Data adapted from Kliegman R, Stanton B, St Geme III J et al (editors): Nelson textbook of pediatrics, ed 20, Philadelphia, 2016, Saunders; Preparation and planning for bioterrorism emergencies. 1446 https://emergency.cdc.gov/bioterrorism/prep.asp. Accessed July 2017. The Mental Health Needs of Parents and Children Terrorist acts in the form of chemical warfare or physical assaults, such as bombings, can be brought into the home via television from remote locations in the United States, thus violating a child’s personal feeling of safety. Children listen to television and to their trusted adults, who are expressing fears; they may lose loved ones or friends; and they may play out their own fears with toys, in art, or through altered behavior. The mental health needs of parents and children after a disaster can be anticipated. They include physical and mental acute distress, increased risk-taking behaviors (e.g., use of alcohol or substance abuse), or manifestations of a specific mental health disorder. Pregnant women are at increased risk of mental health problems and altered pregnancy outcomes. The basic role of the nurse is to establish safety. Move patients to safe areas, and help families care for themselves in a calm manner, maximizing positive thoughts. Help the families maintain a routine for sleep and meals and keep them informed about the situation and what they can and should do to obtain food and supplies and to vent their emotions. Available counseling options should be provided. Children may not understand what is happening, and they may be separated from familiar places and faces, but they can respond positively to helpful adults around them. Families should be kept together whenever possible, and children should have ID tags affixed and secured. Nurses can help parents meet the developmental needs of their children during and after disaster strikes. Online resources to prepare for disaster can be accessed at the website https://emergency.cdc.gov/bioterrorism/prep.asp. The Nurse’s Role in the Community Emergency preparedness The nurse can assist families to prepare for natural disasters, such as hurricanes or floods, or human-created disasters, such as bioterrorist attacks or bombings. The American Medical Association (AMA) has established guidelines to help a family prepare for a community disaster. The guidelines state that the family should keep several days’ supply of food, water, pet food, warm clothing, blankets, copies of vital documents, and toiletries on hand. A battery-powered radio and extra medications, eyeglasses, and basic first aid supplies are also essential. Disaster drills held on a regular schedule should include emergency plans, exit strategies, and out-of-state family contact phone numbers or email addresses. Children should be taught the importance of keeping personal identification with them at all times (perhaps an ID bracelet for infants or small children) and how to call for help when needed (see Online Resources). Initial observation Although the ABCs of emergency triage for adults apply to children, a pediatric quick examination includes: Airway: Assess for blockage or obstruction. Breathing (respiratory effort): Tachypnea may indicate shock, whereas retractions may indicate a lung problem. Circulation: Assess for circulatory problems causing cyanosis, pallor, mottling, or a capillary refill time (CFT) more than 2 seconds. Mental status: Assess that the child is alert, aware of surroundings, and interacting. The initial examination of a patient after suspected exposure to a biological agent may be delayed between exposure and the development of symptoms (incubation period). Tentative triage categories for victims of bioterrorist attacks may include immediate (requiring prompt intervention), delayed (care can wait for a short time), minimal (only outpatient care is required), and expectant (moribund victims unlikely to survive lifesaving measures). A heightened awareness on the part of health care professionals plays a critical role in facilitating early recognition of the release of a biological agent as a weapon. The health care professional must 1447 immediately notify the infection prevention and control department of the hospital, which will work with hospital administration and the local health department. The CDC in Atlanta will be notified of the suspected or confirmed event by the state health department. It is very important that the reporting chain of command be followed. A 24-hour local health department contact number is available to the health care professional. The Pediatric Patient in a Disaster Setting The pediatric patient has a proportionately larger body surface area and thinner skin than an adult. Children may also suffer increased pulmonary problems from the same exposure as adults. Children are closer to the ground and may be more readily exposed to vaporized agents of terror. The immature blood-brain barrier and increased central nervous system (CNS) receptor sensitivity may increase the susceptibility of children to the effects of nerve agents. Vascular access may be difficult in the pediatric patient, and dosage calculations for varied kilogram weights increase the challenge for safe medical therapy for this population. Pediatric autoinjectors of low-dose atropine and pralidoxime are available for treatment of children with severe clinical symptoms after nerve agent exposure. Two physicians, Jim Broselow and Bob Luten, have developed a color-coding system (the Broselow tape) to reduce medication errors in children. Their systems include a water-resistant Pediatric Antidotes for Chemical Warfare tape, which measures the child’s length to determine weight and color zones that correlate to safe dosages of specific emergency drugs commonly used in bioterrorism attacks. This tape is used as a guide in emergency care in the field or hospital emergency departments. 1448 Sexually transmitted infections Overview Sexually transmitted infection (STI) is the general name given to infections spread through direct sexual activity. This term replaces the terms sexually transmitted disease and venereal disease. STIs can be transmitted by a pregnant woman to her unborn child and can cause serious problems in the fetus, such as blindness, birth defects, or death (Table 32.4). The occurrence of an STI in a prepubertal patient should always prompt investigation into the possibility of sexual abuse. (STIs in adults are discussed in Chapter 11.) Table 32.4 Nursing Care to Prevent and Treat Sexually Transmitted Infections in Pediatric Patients Nursing Tip The use of condoms to prevent STIs, although recommended, is not considered 100% effective because condoms are apt to slip or break during intercourse and can be damaged by oil-based lubricants. Nursing care and responsibilities Regardless of the medical professional’s feelings about the changes in society and sexual permissiveness, the consequences of these changes must be recognized and managed. Nurses who wish to help adolescents with STIs must create an environment in which the adolescent feels safe and at ease. Adolescents need emotional support, which the nurse can provide through listening and maintaining a nonjudgmental attitude. The nurse is also responsible for staying up to date on CDC changes in recommended vaccine protocols. The nurse sensitively approaches the patient, recognizing that the adolescent is embarrassed and in need of privacy, especially during examinations. Girls are often afraid and always nervous about a pelvic examination. This is true even when their outward manner may seem otherwise. Careful explanations are needed. The patient is draped appropriately, and the nurse remains during the 1449 examination to provide reassurance. The findings are discussed with the patient, and questions are encouraged. Most adolescents need to be drawn out and do not readily ask questions, even when they do not understand. The requirement to report sexual contacts is an emotionally charged topic that often prevents patients from seeking help. The person who is assured of confidentiality and who has been treated in a dignified manner is more apt to cooperate. Girls who are sexually active must be taught to take responsibility for their own health. Young people must be made aware of the fact that sex with only one partner does not eliminate the risk, because this partner may have had contact with others; the partner needs to have had only one sexual experience with one infected person to transmit disease. The nurse assesses the person’s level of knowledge and provides information at an understandable level. Many young people have little knowledge of their body and their developing sexuality. Others have mild to deep-seated emotional problems that must be addressed. They may be using sex to escape from reality, to express hostility or rebellion, or to call attention to themselves. They may be involved in relationships they no longer desire and therefore need help in formulating positive attitudes toward themselves. They also need help understanding their behavior and that of others. In particular, adolescents must learn that they are responsible for their own actions if they choose to be sexually active. Prevention of STIs is discussed in Chapter 11. Nursing Tip Sex education is not limited to the mechanics of intercourse, but rather includes the feelings involved in a sexual experience: expectations, fantasies, fulfillments, and disappointments. Human Papillomavirus The most common STI in adolescents in the United States is human papillomavirus (HPV). This condition has become endemic in the United States. It is contracted via direct sexual contact, and the risk is increased when multiple sexual partners are involved. Many types of HPV are associated with the development of cancer in both males and females, and HPV may be a significant cause of cervical cancer in women. Manifestations Manifestations include the development of clusters of flesh-colored, cauliflower-shaped warts in the perineal area. Contact with the warts results in spreading of the condition. Prevention There is a licensed vaccine in the United States that can prevent the development of certain strains of HPV if administered before exposure The CDC recommends both males and females receive the two-dose regimen, at least 6 months apart, between 9 and 14 years of age; or, a three-dose regimen between 15 and 26 years of age (CDC, 2016). Parental acceptance of the adolescent vaccine can be increased by emphasizing the values related to cancer prevention for their son or daughter. Treatment The warts can be removed with cryotherapy (freezing the lesion) or electrocautery. Topical treatment with podofilox gel or sinecatechin ointment may also be prescribed. These treatments are not cures, and recurrence is possible. All sexual contact partners also need to be treated. HIV/AIDS in children Pediatric HIV/AIDS is a worldwide public health problem with a devastating outcome. Children usually acquire HIV infection through: Contact with an infected mother at birth (approximately 90% of cases in infants) Sexual contact with an infected person 1450 Use of contaminated needles or contact with infected blood A challenge for public health authorities includes educating the public about the role of unprotected sex and IV drug abuse in increasing the risk of HIV infection. The recommended HIV counseling and testing for pregnant women and highly active antiretroviral therapy (HAART) have played important roles in preventing perinatal transmission (Yogev and Chadwick, 2016). AIDS is caused by a retrovirus known as HIV-1 that attacks lymphocytes (the white blood cells that protect against disease). It thus destroys the body’s ability to fight infection and increases the person’s susceptibility to opportunistic infections that normally would not affect a healthy immune system. AIDS is the advanced stage of HIV infection. Improvements in the treatment of HIV have reduced the incidence of HIV/AIDS in children. Screening of pregnant women and antiretroviral treatment have reduced the mother-to-child transmission of the virus Children do not contract HIV from casual relationships at schools and medical facilities or through family living. The virus is infectious but not highly contagious outside of the body. Because passive transmission of antibodies from the mother occurs, infants are born with antibodies that crossed the placenta. Some infants’ systems become clear of antibodies in about 15 months, whereas other infants eventually experience the infection. In children with perinatal exposure, virologic assay tests (e.g., HIV RNA and HIV DNA nucleic acid tests) are now used to test for HIV infection in children younger than 18 months of age. HIV antibody tests should not be used in infants under 18 months of age (NAM, 2018). Treatment and nursing care The goals of care are to slow the growth of the virus, prevent opportunistic infections, and provide adequate nutrition and supportive therapy. As of 2014, antiretroviral drugs were approved by the FDA for use in children and adolescents. Dosing ranges for children differ from those for adults because of reduced absorption, increased elimination, and an immature liver. Monitoring of blood levels is essential. Dosages for adolescents are based on the Tanner Stage of Development rather than age (Yogev and Chadwick, 2016). Birth control should be available, because most antiviral drugs are teratogenic. Prophylaxis against severe opportunistic infections is available for children. The prognosis has improved, and progression to AIDS has diminished. Psychological support for these children is paramount. Sensory stimulation and touching are especially important for infants. The effects of isolation can be physically and emotionally devastating to the developing child. Many infants are abandoned, outlive their mothers, or must live in foster care. The nurse anticipates interventions related to the care of the child with a life-threatening disease. Efforts to support families in crisis are particularly pertinent. Often assistance from the extended family may be needed. Many families have few financial resources and are exhausted from the child’s frequent hospitalizations and physical care. They may need to be introduced to community agencies, as social service, financial aid, HIV/AIDS and grief support groups, home health, nutritional programs (e.g., Women, Infants, and Children [WIC]), and hospice care. Nursing Tip Rapid HIV tests are offered to high-risk patients. They require a blood sample or an oral swab, and results are available within ½ hour. Traditional tests are used to confirm positive results. Counseling should be available to all patients. Prevention Prevention is the core of education related to HIV/AIDS. Education of adolescents should include methods of transmission, hazards of IV and illicit drug use, and the importance of safe sex practices. The strict use of Standard Precautions when caring for all patients is essential, especially when handling blood and other body fluids. The health education curriculum in elementary school for students and staff should include information concerning HIV/AIDS prevention. Nurses should 1451 encourage high-risk adolescents to undergo counseling and testing, with the hope of modifying risky behaviors. Get Ready for the NCLEX® Examination! Key Points Standard Precautions are techniques recommended by the CDC to prevent the transmission of communicable diseases. Body substance refers to moist secretions of the body that can contain microorganisms. An opportunistic infection is caused by organisms normally found in the environment that the immunosuppressed child cannot fight. Immunization programs in the United States provide active immunity for children. Proper hand hygiene is the basic essential factor in preventing the transmission of infection. Proper storage of vaccines and appropriate routes of administration are essential to ensure the potency of the vaccine. Education of parents about the need for immunizations against common childhood communicable diseases is a primary nursing responsibility. It is the responsibility of the nurse to know when the immunizations are due, the immunization history of the child, contraindications, routes of administration, and which vaccines can be given together. The child should be observed for untoward reactions for at least 20 minutes following immunization. Koplik spots are white spots on the mucous membrane of the oral cavity that occur before a skin rash and are indicative of measles (rubeola) infection. In chickenpox (varicella), all stages of the skin lesions are present on the skin at the same time. A woman in the early months of pregnancy should not care for a child with German measles (rubella), because the virus can cause fetal anomalies. In children with roseola, a persistently high fever suddenly drops as the rash erupts. Gamma globulin offers passive immunity for exposed children who are immunosuppressed. The CDC offers guidelines to help families prepare for community disasters. All nurses must understand their role in the hospital unit when disaster strikes. Maternity and pediatric nurses must understand the special vulnerability of pregnant women and small infants to agents of terrorism. Listening skills and a nonjudgmental attitude are essential when caring for adolescents with STIs. Children acquire the HIV infection by contact with an infected mother at birth, sexual contact with an infected person, or use of contaminated needles during drug use. The long-term nursing goals in the care of a child with HIV are to promote compliance for long-term drug therapy and to provide support to maintain optimum growth and development. Additional Learning Resources Go to your Study Guide for additional learning activities to help you master this chapter content. Go to your Evolve website (http://evolve.elsevier.com/Leifer) for the following learning resources: Animations Answer Guidelines for Critical Thinking Questions 1452 Answers and Rationales for Review Questions for the NCLEX® Examination Glossary with English and Spanish pronunciations Interactive Review Questions for the NCLEX® Examination Patient Teaching Plans in English and Spanish Skills Performance Checklists Video clips and more! Online Resources Advisory Committee on Immunization Practices (ACIP): https://www.cdc.gov/vaccines/acip/recs/index.html Broselow-Luten System: http://slideplayer.com/slide/3293976/ Child health statistics: http://www.childstats.gov National Immunization Program: http://www.cdc.gov/vaccines/ Public health emergency preparedness and response: http://www.bt.cdc.gov; https://emergency.cdc.gov/bioterrorism/prep.asp Smallpox vaccine recommendations: https://www.cdc.gov/vaccines/hcp/acip-recs/vaccspecific/smallpox.html Vaccine Adverse Events Reporting Service: http://www.vaers.hhs.gov Vaccine Information Statements (VISs): http://www.cdc.gov/vaccines/pubs/vis Review Questions for the NCLEX® Examination 1. The nurse is caring for a newborn with HIV/AIDS. What is the priority goal? 1. Encourage breastfeeding 2. Prevent infections 3. Provide initial immunizations 4. Notify social services 2. An adolescent diagnosed with AIDS asks about the mode of transmission for the illness. An accurate response is that it was most likely through: 1. casual contact with a friend who is HIV positive. 2. a latent response to an inherited predisposition. 3. use of a contaminated toilet seat. 4. contact with contaminated body substance through sex or IV needle use. 3. For play therapy for a child with a communicable disease who is in an isolation room, what would be one priority principle or rationale for toy selection? 1. The toy should be selected from the hospital playroom. 2. Most children love books. 3. It is best to bring the child’s favorite toy from home. 4. The toy should be washable. 4. A parent brings a 4-month-old infant to the clinic for the second in the routine immunization series. The nurse should prepare for administration of which immunizations? 1. DTaP, Hib, polio 2. DTaP, polio, MMR 3. DTaP, polio, varicella 4. Td, hepatitis, MMR 5. The DTaP immunization is administered: 1. orally. 2. subcutaneously. 3. intramuscularly. 4. intravenously. 6. The nurse is preparing to administer a live virus vaccine to a 4-month-old infant. Which of the following observations would indicate that the nurse should contact the health care 1453 provider before proceeding? Select all that apply. a. Mother states the infant cried incessantly for hours after the last immunization b. Infant is receiving steroids for a skin problem. c. Infant has mild diarrhea. d. Infant had a temperature of 100.2° F this morning. 1. a and b 2. b and c 3. c and d 4. none of the above 1454 References ☆ Centers for Disease Control and Prevention (CDC). Immunization schedule 2017– 18. https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html. 2018. Centers for Disease Control and Prevention (CDC). Human papillomavirus (HPV). https://www.cdc.gov/mmwr/volumes/65/wr/mm6549a5.htm. 2016. Marchese N., Primer R. Targeting Lyme disease. Nursing 2013. 2013;43(5):28–33. National AIDS Manual (NAM). HIV testing. http://www.aidsmap.com/HIVtesting/page/1060202/#item1374749. 2018. Yogev R., Chadwick E. Acquired immunodeficiency syndrome. In: Kliegman R., Stanton B., St Geme J., Schor N., eds. Nelson textbook of pediatrics. 20 ed. Philadelphia: Elsevier; 2016 2016. ☆ “To view the full reference list for the book, click here” 1455