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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR OTITIS EXTERNA DEFINITION Inflammation of the external auditory canal and auricle caused by a variety of infectious agents. ETIOLOGY The most common cause of otitis externa is accumulation of water in the ear, leading to maceration and desquamation of the lining and conversion of the pH from acid to alkaline (e.g., swimming or frequent showers). It also may be initiated by trauma from scratching (fingernail or cotton-tipped applicator) or poorly-fitting earplugs for swimming. It may also accompany the chronic drainage from a perforated eardrum. NOTE: An infant or child less than 2 years of age must strongly be suspected of having primary otitis media with secondary otitis externa. The most common causative agents are Pseudomonas species and fungi, such as Candida albicans. SUBJECTIVE OBJECTIVE ASSESSMENT 1. Pain and itching in ear(s). 2. Purulent discharge from ear. 3. Occasionally, decrease in hearing, or a sensation of obstruction in the ear(s). 1. Pain aggravated by movement of the pinna tragus (the most common finding). 2. Ear canal may be swollen and erythematous. The client may be resistant to any attempt to insert an ear speculum. 3. Debris and exudate may be seen in the canal; the drum may be impossible to visualize. 4. Pre-auricular and/or post-auricular lymph nodes may be enlarged. 5. Swelling or pain over the mastoid should not be observed in uncomplicated otitis externa. Otitis externa Child Health 10.125 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 PLAN DIAGNOSTIC STUDIES NOTE: Tympanogram is contraindicated due to pain and need to avoid pressure. THERAPEUTIC Therapy centers around the basic principles of: local cleaning of debris and drainage of infection; restoration of the normal acidic protective barrier; judicious use of appropriate local and/or systemic antibiotics; and client education to prevent recurrent infection. PHARMACOLOGIC NOTE: Desquamated epithelium and moist cerumen may need to be removed by gentle irrigation before treatment. 1. For those patients with an intact tympanic membrane: Cortisporin otic solution (not the suspension), instill 3 drops in affected ear canal 3-4 times a day for 10 days OR Children >1 year of age, Cipro HC otic suspension, 3 drops in the affected ear canal twice daily for 7 days. 2. The head should lie with the affected ear upward for medication instillation, and stay in that position for 15 minutes to facilitate penetration of the drops into the ear canal. 3. May take age-appropriate doses of acetaminophen or ibuprofen for pain. NON-PHARMACOLOGIC Preventing external otitis may be necessary for individuals susceptible to recurrences, especially children who swim. The most effective prophylaxis is to place ethyl alcohol 70% 1:1 solution with acetic acid 2% (household white vinegar) in the ear canal immediately after swimming or bathing. CLIENT EDUCATION/COUNSELING 1. Counseling is provided regarding the causes of otitis externa, administration of ear drops, and signs and Child Health 10.126 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 symptoms which indicate the need for further evaluation. 2. Swimming, particularly during the acute phase, should be avoided. Bathing should be done in such a way as to keep the head out of the water, to avoid introducing soapy water and dirt into the ear canal. 3. Keep fingers and instruments (e.g., cotton swabs) out of the ear canals. There is no need to clean canals with swabs. REFERRAL 1. Severe pain, fever or swelling of canal extensive enough to prevent instillation of drops. A cotton wick may be required. 2. Cellulitis of ear or surrounding tissue. 3. Clients with diabetes or other conditions predisposing them to more severe infection. 4. Failure to respond to treatment in 5-7 days. 5. More than one recurrence. 6. History or evidence of local sensitivity to neomycin in ear drops. 7. Tympanic membrane is perforated or not intact. REFERENCES 1. Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24, 2007). 2. Laurence Finberg and Ronald Kleinman, Saunders Manual of Pediatric Practice, 2nd ed., W. B. Saunders, 2002. (Current) 3. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) 4. William W. Hay et al., Current Pediatric Diagnosis and Treatment, 16th ed., McGraw Hill, 2003. (Current) 5. Ferri, Ferri’s Clinical Advisor: Instant Dx and Rx, Mosby, 2007. 6. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, p. 2830. 7. Uphold and Graham, Clinical Guidelines in Family Practice, 4th ed., 2003, pp. 350-351. (Current) 8. Morgan Bernius and Donna Perlin, Pediatric Ear, Nose and Throat Emergencies, Pediatric Clinics of North America 2006, Volume 53, pp 195214. Child Health 10.127 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL ACUTE OTITIS MEDIA DEFINITION Presence of purulent fluid in the middle ear in association with signs and symptoms of acute local or systemic illness. Other terms synonymous with acute otitis media (OM) include: suppurative otitis media, acute bacterial otitis media, and purulent otitis media. Occurs most frequently in winter months in children <7 years old, with highest incidence in children between 6 months and 3 years of age. Commonly seen following a viral upper respiratory tract infection. ETIOLOGY The single most important factor is eustachian tube dysfunction that prevents effective drainage of middle ear fluid. 1. 2. 3. 4. 5. Typically, client has an antecedent event such as an infection or allergy that results in edema and congestion of the mucosa of the nasopharynx, eustachian tube, and middle ear. The congestion of the eustachian tube impedes the flow of middle ear secretions. Negative pressure often increases, which further pulls fluid into the middle ear. As middle ear secretions increase, microbial pathogens grow and result in otitis media. Common pathogens are: a. Streptococcus pneumoniae. b. Haemophilus influenzae. c. Moraxella catarrhalis. d. Viruses. e. Other bacteria such as Streptococcus pyogenes and Staphylococcus aureus. Recently, there has been an increase in infections due to beta-lactamase producing organisms (M. catarrhalis and H. influenzae) and drug-resistant S. pneumoniae. Recurrent episodes of otitis media may be related to anatomical or physiological eustachian tube abnormality. Predisposing factors for developing otitis media include: 1. Active or passive smoking. 2. Caucasian or Native American race. 3. Males. 4. Congenital disorders (e.g., cleft palate, trisomy 21). 5. Family history of otitis media. Child Health 10.128 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 SUBJECTIVE OBJECTIVE Client may have: 1. Earache, vertigo. 2. Symptoms of upper respiratory infection. 3. Fever. 4. Difficulty hearing. 5. No symptoms, or just irritability. 1. Signs: a. b. c. d. 2. Complications include hearing loss and perforation of the tympanic membrane (TM). Characteristically TM has the following appearance: a. b. c. d. e. f. 3. Otorrhea, decreased hearing. Fever is common but not always present. May have no signs, just behaviors perceived as irritability, primarily in children. Vomiting and diarrhea, primarily in children. Full or bulging, opague TM. Absent or obscured bony landmarks. Distorted light reflex. Decreased or absent mobility of TM by pneumatic otoscopy. Erythema of TM is an inconsistent finding; TM may be red due to crying or vascular engorgement due to fever rather than infection. Bullae may form between layers of TM, especially with Mycoplasma pneumoniae. Diagnostic criteria: a. b. Documented bulging or rupture of TM. Signs or symptoms of acute local or systemic illness (e.g., fever or ear pain). ASSESSMENT Acute Otitis Media PLAN DIAGNOSTIC STUDIES 1. Usually no diagnostic tests are indicated. Child Health 10.129 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 2. Tympanometry may be indicated in recurrent cases and when there is suspicion of fluid behind the TM without clinical signs. 3. Acoustic reflectometry helps diagnose OM by analyzing sound pressure and reflected sound in the eardrum. THERAPEUTIC NOTE: Be cautious. 80% of cases resolve spontaneously. Prescribe antibiotics sparingly. They improve resolution by only about 15% and increase the risk of bacterial resistance. The AAP and the AFP recently released the following guidelines for withholding antibiotic treatment: Age 6 months-2yrs: If the diagnosis is uncertain (difficult examination, conflicting findings, etc.) and infant is nontoxic, minimal irritability well-controlled with acetaminophen/ibuprofen, has low-grade fever and reliable follow-up. Age greater than 24 months: If the child is non-toxic, has pain that is well controlled with acetaminophen/ibuprofen, has low-grade fever and reliable follow-up. NOTE: For this age, certainty or uncertainty of the diagnosis is not a factor. PHARMACOLOGIC Persistent middle ear effusion for 2-3 months after therapy for OM is expected and does not require therapy, in the absence of clinical symptoms. Recommended antibiotic regimens: 1. Initial treatment, not penicillin allergic – Amoxicillin according to dosing chart below. 2. Initial treatment, penicillin allergic – Azithromycin according to dosing chart below. 3. Failure of initial treatment, not penicillin allergic – Amoxicillin/Clavulinic Acid (Augmentin) OR Azithromycin according to dosing charts below. 4. Failure of initial treatment, penicillin allergic – Refer (a cephalosporin may be required; however, there is risk of an allergic reaction to cephalosporins in the penicillin allergic patient.) Child Health 10.130 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 Recommended First-Line Antibiotics for Medical Management of Otitis Media Generic/Trade Names & Strength Amoxicillin/Amoxil 125 mg/5mL, 200mg/5mL, 250 mg/5mL, 400mg/5mL Chewable: 125mg 200mg 250mg 400mg Dosing Duration Children > or = 3 months and < 40 kg: Initial treatment: 80-90 mg/kg/day PO divided as either bidtid 10 days Children > 40 kg: 250 mg-500 PO mg tid OR (only for penicillin allergic clients or clients for whom compliance with the 10-day/twice daily Amoxicillin therapy is likely to be a problem) > 6 months of age See dosing charts below Azithromycin 100mg/5mL 200mg/5mL 250 mg capsule 5 day regimen: 10mg/kg (maximum dose 500 mg/day) PO on day 1, then 5mg/kg (maximum dose 250 mg/day) PO days 2-5 3 day regimen: 10mg/kg (maximum dose 500mg/day) PO daily for 3 days Single dose regimen: 30mg/kg (maximum dose 1500mg) PO single dose Single dose regimen-higher incidence of nausea/vomiting Child Health 10.131 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 OTITIS MEDIA: (5-Day Regimen for Azithromycin) Dosing Calculated on 10 mg/kg/day PO Day 1 and 5 mg/kg/day PO Days 2 to 5 Weight 100 mg/5 mL 200 mg/5 mL Day 1 Total mg per Treatment Course Kg Lbs Day 1 Day 25 5 11 2.5 mL (½ tsp) 1.25 mL (¼ tsp) 7.5 mL 150 mg 10 22 5 mL (1 tsp) 2.5 mL (½ tsp) 15 mL 300 mg 20 44 5 mL (1 tsp) 2.5 mL (½ tsp) 15 mL 600 mg 30 66 7.5 mL (1½ tsp) 3.75 mL (¾ tsp) 22.5 mL 900 mg 40 88 10 mL (2 tsp) 5 mL (1 tsp) 30 mL 1200 mg 50 and above 110 and above 12.5 mL (2½ tsp) 6.25 mL (1¼ tsp) 37.5 mL 1500 mg Child Health Day 25 Total mL per Treatment Course 10.132 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 OTITIS MEDIA: (3-Day Regimen for Azithromycin) Dosing Calculated on 10 mg/kg/day PO Weight Lbs Kg 100mg/5mL Day 1-3 200mg/5mL Day 1-3 Total mL per Treatment Course Total mg per Treatment Course 5 11 2.5 mL (½ tsp) 7.5 mL 150 mg 10 22 5 mL (1 tsp) 15 mL 300 mg 20 44 5 mL (1 tsp) 15 mL 600 mg 30 66 7.5 mL (1½ tsp) 22.5 mL 900 mg 40 88 10 mL (2 tsp) 30 mL 1200 mg 50 and above 110 and above 12.5 mL (2½ tsp) 37.5 mL 1500 mg OTITIS MEDIA: (1-Day Regimen for Azithromycin) Dosing calculated on 30 mg/kg PO as a single dose Weight Kg 200 mg/5 mL Lbs. Day 1 Total mL per Treatment Course 3.75 mL Total mg per Treatment Course 150 mg 5 11 3.75 mL (3/4 tsp) 10 22 7.5 mL (1 ½ tsp) 7.5 mL 300 mg 20 44 15 mL (3 tsp) 15 mL 600 mg 30 66 22.5 mL (4 ½ tsp) 22.5 mL 900 mg 40 88 30 mL (6 tsp) 30 mL 1200 mg 50 and above 110 and above 37.5 mL (7 ½ tsp) 37.5 mL 1500 mg Child Health 10.133 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 AMOXICILLIN/CLAVULANIC ACID (Augmentin) The following dosage chart provides guidelines for dosing at 90 mg/kg/day. If a more accurate dose is desired, the dose may be calculated individually by patient weight. NOTE: The American Academy of Pediatrics and the American Academy of Family Physicians recommend that a 10-day regimen be used for treatment of Acute Otitis Media in children younger than 6 years of age but that a duration of 5-7 days may be appropriate in those 6 years of age or older. Dosage should not exceed 1750 mg daily. WEIGHT DOSE - 90 mg/kg/day (q12h 400 mg strength) (Lb) (kg) 400 mg/5 mL (400 mg tab) 10 5 3 mL q 12h (0.5 tablet q 12h) 20 9 5 mL q 12h (1 tablet q 12h) 30 14 8 mL q 12h (1.5 tablets q 12h) 40 18 10 mLq 12h (2 tablets q 12h) 60 27 10 mLq 12h (2 tablets q 12h) 80+ 36+ 10 mLq 12h (2 tablets q 12h) SUPPLIED: SUSPENSION: 50 mL, 75 mL, 100 mL and 150 mL. o 400 mg Amoxicillin and 57 mg Clavulanic Acid/5 mL, Orange/Raspberry. CHEWABLE TABLET: 20s, 30s o 400 mg Amoxicillin and 57 mg Clavulanic Acid, Cherry-banana. NON-PHARMACOLOGIC Modify risk factors to improve the odds of resolution: 1. 2. 3. 4. 5. 6. Avoid passive smoking. Control food and inhalant allergies. Treat sinusitis. Limit pacifier use after age one year. Consider alternatives to group day care. Practice prevention: encourage breast feeding; advise parents not to prop infant’s bottle and to elevate infant’s head when feeding; consider pneumococcal vaccine; consider influenza vaccine. Child Health 10.134 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 CLIENT EDUCATION/COUNSELING 1. Avoid unproven therapies, antihistamines, decongestants, homeopathy and naturopathy and folk remedies such as “sweet oil.” 2. Administer acetaminophen or ibuprofen for fever or pain discomfort. Refer to the acetaminophen and ibuprofen dosage chart listed in the Nurse Protocol for Fever. 3. Children with otitis media may return to school as soon as the fever is gone and they feel better. Otitis media is not contagious. 4. Give the complete amount of antibiotics. 5. Common side effects, storage of antibiotics (if refrigeration required), interactions, and when the antibiotic will expire and any other pertinent patient drug information. 6. Keep fingers and instruments (e.g., cotton swabs) out of the ear canals. 7. Importance of keeping follow-up appointments. FOLLOW-UP 1. Return to clinic in 2-3 days if condition is not significantly improved. 2. Return visit several days after completion of antibiotic therapy or recheck in 2-3 weeks from initial visit. If the child is >15 months old and asymptomatic, visit may be scheduled for 4-6 weeks, if parents/client report that the infection has resolved. REFERRAL 1. Clients who appear toxic, are not drinking and voiding, or are immunocompromised. 2. If condition is not significantly improved in 2-3 days, or fever and pain are not resolved after 48 hours of antibiotic therapy. (May consider amoxicillin/clavulinic acid for an additional 2-3 days before referral if the child is nontoxic.) Child Health 10.135 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 3. Signs and symptoms of meningitis: persistent lethargy, extreme irritability; stiff neck (unable to touch chest with chin). Substantial cough, rash, vomiting or other signs or symptoms that suggest illness beyond simple otitis media. 4. Infants less than 2 months of age. 5. Significant pain not relieved by acetaminophen or ibuprofen. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. Constance R. Uphold, and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Inc., Gainesville, FL, 2003. (Current) Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24 , 2007). S. Pelton, Otitis Media: Re-evaluation of diagnosis and treatment in an era of antimicrobial resistance, pneumococcal conjugate vaccine, and evolving morbidity, Pediatric Clinics of North America 2005, Volume 52, pp. 711-728. Product Information Augmentin ES-600™, 2001. (Current) American Society of Health-Systems Pharmacists, American Hospital Formulary Service, Bethesda, MD, 2007, pp. 160-176,231-246, 310-316. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003, p. 2344. (Current) Pfizer Inc, Zithromax (azithromycin tablets and azithromycin for oral suspension), August 2007, <http://www.pfizer.com/download/uspi_zithromax.pdf>. Mathew J. Neff. AAP, AAFP release guidelines on diagnosis and management of AOM, American Family Physician, 69:2713, 2004. (Current) Child Health 10.136 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR PEDICULOSIS CAPITIS (Head Lice) DEFINITION Infestation of the head by Pediculus humanus capitis. It is most common in school-age white females. ETIOLOGY The head louse attaches to hair. Females lay eggs embedded in water-insoluble glue that adheres the eggs to the hair shaft. Eggs hatch after 4 to 14 days. The lice ingest blood every few hours and can only survive 1 to 2 days away from a blood supply. Transmission occurs by direct contact, such as sharing hairbrushes, caps or clothing, or through close living quarters. SUBJECTIVE 1. Itching. 2. Rash. 3. Nits or adult lice seen. 4. May give history of exposure to lice. 1. Identification of lice or nits attached to head hair, eyebrows or eyelashes. Adult lice are hard to find, usually <10/patient. With recent infestation, eggs are a creamy-yellow color. Empty eggshells are white. Common sites are the back of the head and behind the ears. Nits are firmly attached to the hairs and cannot be moved up and down the hair shaft like hair casts, scales and dandruff. 2. Small red papules or secondary excoriations. 3. Occipital or cervical lymphadenopathy may be present. OBJECTIVE ASSESSMENT Pediculosis capitis (Head lice) PLAN THERAPEUTIC PHARMACOLOGIC 1. Permethrin 1% cream rinse (nonprescription NIX). Do not use NIX on pregnant females, infants less than 2 months old, or on patients who are allergic to synthetic pyrethroid or pyrethrin, any of its components or chrysanthemums. Child Health 10.137 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 a. b. c. d. e. Apply NIX to shampooed, rinsed and completely dried hair and wash off after 10 minutes. (Do not apply to damp hair.) Comb with a fine-tooth comb to remove nits and re-evaluate scalp for secondary infection. Repeat application in >7 days if live lice are seen. Re-treatment for recurrences is required in less than 1% of patients. Treatment with NIX may temporarily exacerbate pruritus, erythema, or edema. Clients may experience mild transient burning/stinging, tingling, numbness, or scalp discomfort. If any reaction persists, refer client to a private care provider. To prevent accidental ingestion, NIX should be stored in a locked area out of reach of children. OR 2. Pyrethrins with piperonyl butoxide (e.g., nonprescription A-200, RID, Clear, Pronto) apply enough solution to completely wet hair, add water to lather, wait 10 minutes and rinse thoroughly with warm water. Use fine-toothed comb to remove lice and eggs from hair, shampoo hair to restore body and luster. Repeat application in 7-10 days. A-200 may be preferred because its benzyl alcohol base has pediculosidal activity. OR 3. For resistance to permethrin and pyrethrins which is becoming increasingly common in the US: Malathion (e.g., prescription Ovide). Do not use under age 6 yrs. Apply to dry hair. Allow to dry naturally; do not use an electric heat source. Eight (8) hours later, shampoo and rinse. Then comb with a finetoothed metal comb. If necessary, repeat in 7-9 days. 4. For infestation of the eyelids or eyebrow, apply petrolatum ointment to eyelid margins or eyebrow bid for 8-10 days, followed by removal of nits. Child Health 10.138 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 5. Mild topical antipruritic/anti-inflammatory cream or ointment may be obtained over-the-counter for itching. 6. Evidence of secondary infection requires systemic antibiotic treatment. The patient should be assessed for impetigo treatment or physician referral. NON-PHARMACOLOGIC 1. As an alternative to pediculocides, as prevention following exposure to head lice, or when previous treatments appear to have been unsuccessful: a. To dry hair, apply a generous amount of olive oil, petroleum jelly, mayonnaise, any vegetable oil, or baby oil to the scalp. Massage well to distribute over all the hair. b. Cover the head with a shower cap and leave the oil on overnight, or at least 8 hours. c. In the morning, or after 8 hours, comb the hair with a regular comb to remove any tangles. Comb with a nit comb through very small sections of hair. Be sure to wipe the comb often. d. When all nits have been removed, shampoo hair. A second application of shampoo may be necessary to remove all of the oil. e. Dry the hair as usual. Blow dryer temperatures can kill lice. f. Check carefully for nits by parting off small sections of hair and looking under a very bright light. g. If done properly, there is no need to repeat. All lice should be suffocated, and all nits removed. OR 2. Remove nits with comb or tweezers. To aid in removal, soak hair with a 1:1 white vinegar:water solution. Cover the hair with a warm moist towel for 30-60 minutes, then comb. A product called “Step 2" which contains formic acid may be used to facilitate nit removal. Formic acid dissolves the cement that attaches the nit to the hair. It is applied to the hair after the pediculocide, left on for 10 minutes, then rinsed. Child Health 10.139 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 3. Adequate washing or dry-cleaning of clothes and linens used during the previous few days. Any item that cannot be washed or dry-cleaned should be stored in a plastic bag for two weeks. 4. Soak brushes, combs and hair accessories in hot water with pediculocide shampoo or alcohol for an hour. 5. Vacuum mattresses, pillows, upholstered furniture, and carpeting. Discard the vacuum cleaner bag. Fumigation of the home is not recommended. CLIENT EDUCATION/COUNSELING 1. Contacts should be treated only if infestation is found. 2. Teach how to apply prescribed medication and decontaminate clothing and other articles. 3. Flush the eyes with water immediately if pediculocide gets in the eyes. 4. Avoid unnecessary re-treatment because of the toxic hazard. 5. Itching may persist for 1-2 weeks even after adequate treatment, and should not be considered a reason for reapplication of medication. 6. Educate about the person-to-person mode of transmission, and procedures to prevent transmission. a. Do not share combs, brushes or head gear/coverings with other persons. b. Hang coats where they do not touch those of other persons. 7. Assure that head lice infestation is a common problem in the school-age population and affects children of all socioeconomic groups. 8. Instruct caregiver that child may return to daycare or school the next day after first treatment for head lice. It is not recommended that child be excluded from school based on the presence of nits. 9. Client may ask about the use of hot air to cure head lice. Child Health 10.140 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 Only one article has studied this therapy. It evaluated six different methods of delivering hot air to the scalp. All methods demonstrated substantial egg destruction but only one method was highly effective against hatched lice and demonstrated a high long-term cure rate. This method requires a special device for delivering hot air to the scalp which is not yet commercially available. Using a simple hair dryer to expose the hair and scalp to hot air was not effective and should not be recommended. FOLLOW-UP 1. Reevaluate in one week if symptoms persist. 2. Re-treatment may occasionally be necessary. Use an alternate regimen if not responding to treatment. REFERRAL Consult with physician regarding any question of management. REFERENCES 1. Catherine E. Burns, et al., Pediatric Primary Care, A Handbook for Nurse Practitioners, 2nd ed., W.B. Saunders, Philadelphia, PA, 2000. (Current) 2. Thomas B. Fitzpatrick, et al., Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases, 4th ed., McGraw-Hill, New York, NY, 2001. (Current) 3. Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24 , 2007). 4. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, pp. 3505-3510. 5. Constance R. Uphold, and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Inc., Gainesville, FL, 2003, pp. 294-295. (Current) 6. American Academy of Pediatrics, Red Book: Report of the Committee on Infectious Diseases, 27th ed., 2006, p. 488. (Current) 7. Christine J. Ko & D. M. Elston, Pediculosis, Journal of American Academy of Dermatology, 50:1-12, 2004. (Current) 8. Georgia Department of Human Resources Division of Public Health, Children's Healthcare of Atlanta, & Georgia Association of School Nurses, Georgia School Health Resource Manual, 2004. (Current) 9. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 <http://online.factsandcomparisons.com>. 10. Laurie Barclay and Desiree Lie, Hot air may be an effective non-chemical treatment of head lice, Pediatrics, 2006, Volume 118, pp. 1962-1970. Child Health 10.141 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR PHARYNGITIS DEFINITION Inflammation of the pharynx, and surrounding lymph tissue (tonsils). ETIOLOGY Viral causes: 1. Rhinoviruses. 2. Adenoviruses. 3. Herpangina due to Coxsackie virus and echovirus. 4. Hand-foot-and-mouth disease due to Coxsackie virus. 5. Infectious mononucleosis caused by Epstein-Barr virus. 6. Human immunodeficiency virus (HIV). Bacterial causes: 1. Group A beta-hemolytic streptococcus. 2. Neisseria gonorrhoeae. 3. Corynebacterium diphtheriae. 4. Streptococci of Lancefield Group C and G (often associated with contaminated food). 5. Chlamydia trachomatis. Other causes: 1. Mycoplasma pneumoniae. 2. Candida albicans. 3. Noninfectious causes: a. Allergic rhinitis or post-nasal drip. b. Mouth breathing. c. Trauma from heat, alcohol, irritants such as marijuana, or sharp objects. d. Subacute thyroiditis in females. SUBJECTIVE OBJECTIVE Client may complain of: 1. Fever, headache and malaise, often accompanied with sore throat and difficulty swallowing. 2. Small oral vesicles or ulcers on tonsils, pharynx, or posterior buccal mucus. 1. Pharyngitis due to Group A beta-hemolytic streptococcus: (Common in school-age children; uncommon if <3 yrs old; rare in adults.) a. Fever >101o F. Child Health 10.142 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 b. c. d. e. f. 2. Pharyngitis due to Corynebacterium diphtheriae: a. b. 3. Erythema of tonsils and pharynx with white or yellow exudate. Tender and enlarged anterior cervical lymph nodes are often present. Abdominal pain, vomiting, and headache may occur, but upper respiratory symptoms suggest other causes of pharyngitis. Improper antimicrobial treatment, can lead to serious suppurative (direct extension from pharynx) and nonsuppurative complications arising from immune responses to acute infections (rheumatic fever). (with selected strains) A scarlatiniform rash – a blanching erythematous rash with a sandpaper texture that is diffusely distributed but is most prominent in the intertriginous areas. Gray adherent membrane on the nasal mucosa, tonsils, uvula or pharynx. Bleeding occurs when membrane is removed. Pharyngitis due to Neisseria gonorrhoeae and Chlamydia trachomatis: (Seen in clients who practice orogenital sex. Consider sexual abuse if a child.) Commonly presents as a chronic sore throat. 4. Pharyngitis due to Mycoplasma pneumoniae: (Uncommon in children <5 years of age; common in adolescents and adults.) Signs and symptoms indistinguishable from streptococcal disease. 5. Pharyngitis due to Candida albicans: a. b. 6. Thin diffuse or patchy exudate on mucous membranes. Clients have history of antibiotic use or are immunocompromised. Peritonsillar abscess: (Most common in older children and adults following an episode of tonsillitis.) Child Health 10.143 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 a. b. c. d. e. 7. Signs are frequently associated with gradually increasing unilateral ear and throat pain, dysphagia, dysphonia, neck stiffness, drooling, and trismus. The affected tonsil is usually grossly swollen medially, erythematous, and may displace uvula and soft palate to contralateral side. Swelling and erythema of the soft palate is noted. Fluctance may be felt with palpation of affected side. Usually, enlarged and very tender lymph nodes. Pharyngitis due to infectious mononucleosis (mono): a. b. Symptoms and objective findings similar to those for streptococcal pharyngitis. Spleen may be enlarged. ASSESSMENT Pharyngitis PLAN DIAGNOSTIC STUDIES 1. Collect specimens for a rapid strep test and throat culture at the same time. If the rapid test is negative (may be falsely negative in approximately 10% of cases) and suspicion is high, send throat culture to laboratory (specify need to look for Neisseria or Chlamydia). To maximize yield, both tonsils AND the posterior pharynx should be swabbed. 2. Consider monospot test if client has been ill for at least 5-7 days. 3. Consider CBC with differential. Atypical lymphocytes are seen with mono. THERAPEUTIC PHARMACOLOGIC 1. For viral pharyngitis, treatment is symptomatic. 2. Antibiotic treatment for possible and probable strep throat, if positive throat culture or positive antigen-detection test. Child Health 10.144 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 Antibiotic Treatment for Possible and Probable Strep Throat NOTE: If positive throat culture or positive antigen-detection test. Antibiotic Dosage Duration/Comments Penicillin V Child < 27kg: 250mg PO bid 10 days 125 mg/5 mL suspension 250 mg/5 mL suspension 250 mg tablets Child > 27kg/adult: 500mg PO bid OR Amoxicillin 125mg/5mL suspension 250mg/5mL suspension 250 mg chewable tabs OR Benzathine penicillin (When compliance with oral med a concern) Child > 3 months and < 40 kg: 50mg/kg/day PO every 8 – 12 hours to a max of 750mg 500mg BID or TID Child < 27kg: 600,000 units IM x 1 Child >27kg/adult: 1,200,000 units IM x 1 OR For penicillin-allergic children Child: (EES) 40 mg/kg/day PO 2-4 divided doses Erythromycin ethylsuccinate (EES/Eryped) 200 mg/5mL suspension 400 mg/5mL suspension Erythromycin base (E-Mycin, Ery-Tab) 250 mg, 333 mg, 500 mg 10 days - Observe for 30 minutes after injection, for possible anaphylaxis - To reduce discomfort, bring medication to room temperature before injecting 10 days Maximum dose in children for ethylsuccinate is 3.2 gm/day PO Adult: (E-mycin, Ery-Tab) 250 mg PO q 6 hours OR 333 mg PO q 8 hours OR 500 mg PO q 12 hours Severe infections may require increased dosages. Maximum dose of 2 gm/day. If dosages exceed 1gm/day the q12 hour dosing is not recommended. OR Child Health 10.145 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 Azithromycin (Zithromax) 100mg/ 5mL suspension 200mg/5mL suspension 250mg capsule OR Cefdinir (Omnicef) 300mg capsule 125mg/5mL suspension Child > 2 years: 12 mg/kg/day PO as a single dose to a max of 500mg 14mg/kg/day PO divided bid to a max of 600mg per day 5 days 10 days NOTE: Do not give to clients allergic to penicillin. OR Cefadroxil (Duricef) 250mg/5mL suspension 500mg/5mL suspension 500 mg capsule 30mg/kg PO as a single dose or divided into 2 equal doses 10 days Max dose 2 gm/day NOTE: Do not give to clients allergic to penicillin. Adult: 500mg PO bid CLIENT EDUCATION/COUNSELING 1. Seek health care immediately if the pain becomes more severe or if dyspnea develops, or if drooling, stiff neck, possible dehydration, difficulty swallowing, or inability to fully open the mouth occurs. 2. Increase fluid intake. 3. May use hard candy, lozenges, or warm saline to soothe throat. 4. Clients with streptococcal pharyngitis should not return to school or work until they have been on antibiotic therapy for a full 24 hours. 5. Will usually feel well within 24-48 hours, but it is important to take the full 5 or 10-day course of antibiotic to prevent complications, particularly rheumatic fever. 6. Common side effects of the antibiotic, storage, interactions, when the drug will expire and any other pertinent information. Child Health 10.146 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 7. Discard or sanitize old toothbrush. Sanitize toothbrush by rinsing with hydrogen peroxide or Listerine® after each use until the antibiotic course is completed. Get a new toothbrush after antibiotic course is completed. 8. Observe for and return if there is discolored urine, arthritis or failure to improve after 48 hours. FOLLOW-UP 1. If no significant improvement in 3-4 days, client should return to health care provider. 2. Post-treatment throat cultures for clients with streptococcal pharyngitis if there is a suspicion of a strep carrier state (recurrent positive strep tests). REFERRAL 1. Complications of streptococcal pharyngitis. 2. Recurrence of streptococcal pharyngitis. 3. Peritonsillar abscess. 4. Mononucleosis. REFERENCES 1. Constance R. Uphold and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Inc., Gainesville, FL, 2003. (Current) 2. Lexi-Drugs OnlineTM, “Lexi-Comp Database,”TM Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24 , 2007). 3. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) 4. American Society of Health-Systems Pharmacists, American Hospital Formulary Services, 2007, pp. 103-104, 125-127,222-228, 231-246, 281-284, 306-309. 5. Robert Rakel, Conn’s Current Therapy, 57th ed., Eisevier, 2005. 6. Sarah Long et al., Principles and Practice of Pediatrics Infectious Disease, Churchill Livingston, 2003, p. 182. (Current) 7. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 <http://online.factsandcomparisons.com>. 8. Feder, H.M Jr., Gerber, M.A., Randolph, M.F., Shelmach, P.S., Kaplan, E.L., “Once-daily therapy for streptococcal pharyngitis with amoxicillin”, Pediatrics, Vol. 103, January 1999, pp. 47-51. (Current) Child Health 10.147 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 9. 10. Michael Gerber, Diagnosis and treatment of pharyngitis in children, Pediatric Clinics of North America, 2005, Volume 52, pp 729-747. H. Clegg, et al., Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin: a noninferiority trial, Pediatric Infectious Disease Journal, 2006, Volume 25, pp 761-767. Child Health 10.148 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR PINWORMS DEFINITION A parasitic nematode causing infestation of the intestines and rectum. Up to 30% of children in the United States have pinworms. Pinworms are indigenous to the climate of the southern United States, usually affecting young children and their families. Adult worms are 5-10 mm long and live in the colon. Females deposit eggs on the perianal area, primarily at night, causing intense pruritis. Scratching contaminates the fingers and allows transmission back to the host or to contacts. ETIOLOGY The nematode, Enterobius vermicularis. SUBJECTIVE 1. May be asymptomatic. 2. Nocturnal perianal pruritus is the primary symptom. 3. Young females may experience genital irritation with vulvovaginitis and dysuria. 4. History of caretaker’s observation of worms in anal area at night while child is sleeping. 5. Other symptoms may include anorexia, enuresis, insomnia, and grinding teeth during sleep. 1. Diagnostic Criteria OBJECTIVE 2. ASSESSMENT a. Laboratory identification of eggs from perianal area: b. Apply transparent adhesive tape to the perianal area to pick up any eggs; apply tape to a glass slide and examine under a low-power microscope. (Obtain specimens in the early morning before client bathes or defecates.) OR Observation of pinworm(s) during exam. May have local irritation or secondary infection of scratched skin. Pinworms Child Health 10.149 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 PLAN THERAPEUTIC PHARMACOLOGIC 1. 2. If not pregnant, lactating, taking carbamazepine, cimetidine, or phenytoin, or a child <2 years old: Mebendazole (Vermox) 100 mg chewable tablet PO as a single dose, with food. Repeat in 14 days. OR If not pregnant, lactating, taking piperizine, theophylline, or an infant <2 years old, and does not have liver disease: Pyrantel pamoate (Pin-X, Pyrantel Pamoate Suspension), available as suspension of 250 mg/5 mLand a caplet form containing 62.5 mg per caplet. a. b. 11mg/kg/dose (maximum 1 gram) as a single dose PO OR 1 mL (50 mg) per 5 kg (11 lbs) of body weight as a single dose PO per the following chart: Dosage Weight Suspension 25-37 lbs. (11-16 kg) 2.5 mL= ½ tsp. 38-62 lbs. (17-28 kg) 5 mL= 1 tsp. 63-87 lbs. (29-39 kg) 7.5 mL= 1 ½ tsp. 88-112 lbs. (40-50 kg) 10mL= 2 tsp. 113-137 lbs. (51-62 kg) 12.5 mL= 2 ½ tsp. 138-162 lbs. (63-73 kg) 15mL= 3 tsp. 163-187lbs. (74-84 kg) 17.5 mL= 3 ½ tsp. 188 lbs. and over 20mL = 4 tsp. NOTE: Do not use with history of liver disease. Caplet 2 caplets 4 caplets 6 caplets 8 caplets 10 caplets 12 caplets 14 caplets 16 caplets NOTE: If client weighs less than 25 lbs. or is <2 years old, consult with a physician. c. 3. Repeat treatment once in 14 days. Treat all household members simultaneously, with one of the above regimens. CLIENT EDUCATION/COUNSELING 1. Consult a physician if medication side effects such as Child Health 10.150 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 anorexia, abdominal cramps, nausea, vomiting, diarrhea, headache, or dizziness persist. 2. Stress personal hygiene, particularly hand washing before eating and after using the toilet. 3. Pajamas and bed linens of symptomatic family members should be washed in regular laundry detergent after treatment. 4. Upholstered furniture and carpet should be vacuumed. Other flooring should be wet mopped. 5. Bathe immediately upon arising for several mornings after treatment. REFERRAL 1. Child under 2 years of age or weighing less than 25 pounds. 2. Pregnant or lactating. 3. Clients with any of the other conditions listed above that are contraindications for treatment or who are on drugs that adversely interact with mebendazole or pyrantel pamoate. 4. Clients who develop side effects from treatment. REFERENCES 1. Frederic D. Burg et al., Gellis and Kagan’s Current Pediatric Therapy, 17th ed., W. B. Saunders, 2002. (Current) 2. William W. Hay et al., Current Pediatric Diagnosis and Treatment, 16th ed., McGraw-Hill, 2003. (Current) 3. G. K. Siberry and R. Iannone, The Harriet Lane Handbook, Drug Doses, 15th ed., 2000. (Current) 4. American Academy of Pediatrics, Red Book: Report of the Committee of Infectious Disease, 27th ed., 2006, pp. 520-522. 5. American Society of Health-Systems Pharmacists, American Hospital Formulary Services, 2007, pp. 51-53, 57-58. 6. Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24 , 2007). 7. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 <http://online.factsandcomparisons.com>. 8. Troy Moon and Richard Oberhelman, Antiparasitic therapy in children, Pediatric Clinics of North America 2005, Volume 52, pp. 917-948. Child Health 10.151 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR PITYRIASIS ROSEA DEFINITION A self-limiting, mild, scaly skin eruption occurring primarily in adolescents and young adults, lasting from 4-8 weeks or up to 3 months. ETIOLOGY Unknown. Presumed to be a virus. SUBJECTIVE 1. May report prodrome of pharyngitis, lymphadenopathy, headache and malaise. 2. Mild itching during the first week of the eruption. 3. May have no constitutional symptoms. 1. An annular, scaly, erythematous lesion (the herald patch) precedes the appearance of the remainder of the lesions by 1-30 days in 80% of children. It is usually on the trunk, but may appear on the face or extremities. The herald patch shows central clearing and may mimic tinea corporis. 2. Multiple erythematous macules progressing to small, red papules appearing over the trunk. The papules enlarge, becoming oval. 3. Distribution of the rash is along the lines of skin stress giving a “Christmas tree" appearance on the trunk. 4. In African Americans, may find lesions over the proximal extremities, inguinal and axillary areas and neck, with few lesions on the trunk. OBJECTIVE ASSESSMENT Pityriasis rosea PLAN DIAGNOSTIC RPR if secondary syphilis is suspected. (It is very important to refer client if there is history of sexual activity or a genital lesion.) Child Health 10.152 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 THERAPEUTIC PHARMACOLOGIC (if pruritis is a problem) Loratadine (e.g., Claritin) 5mg/5mL solution, 10mg tablets: 2-5 years of age, 5 mg PO once daily 6 years of age, 10mg PO once daily OR Diphenhydramine HCl (e.g., Benadryl) liquid elixir 12.5 mg/5 mL: Child 2-5 years of age: 6.25mg q 4-6 h, maximum 37.5mg/day Child > 6 years to 11 years of age: 12.5-25mg q 4-6 hours, maximum 150mg/day Child 12 years of age and older: 25-50mg q 4-6 hours, maximum 300mg/day NON-PHARMACOLOGIC 1. Bland emollient lotion or cream for scaly skin. 2. Cool, tepid baths. 3. Avoid strenuous physical activity that increases perspiration and aggravates the condition. CLIENT EDUCATION/COUNSELING 1. Inform the client/caretaker that the rash will last several weeks but is self-limiting. Temporary skin discoloration may follow the rash. 2. Encourage the client to avoid scratching the lesions. CONSULTATION/REFERRAL 1. Signs of secondary infection due to scratching lesions. 2. Suspect secondary syphilis (RPR indicated). 3. Severe itching. Child Health 10.153 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 REFERENCES 1. 2. 3. 4. 5. 6. 7. William W. Hay et al., Current Pediatric Diagnosis and Treatment, 16th ed., McGraw Hill, 2003. (Current) William L. Weston, et al., Color Textbook of Pediatric Dermatology, 3rd ed., Mosby-Year Book Inc., 2002. (Current) Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, 2003. (Current) Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 <http://online.factsandcomparisons.com>. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, pp. 15-19, 36-42. Fred Ferri, Pityriasis Rosea, Ferri’s Clinical Advisor 2007: Instant Diagnosis and Treatment, 2007, p 690. Lexi-Drugs OnlineTM, Lexi-Comp DatabaseTM, Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24 , 2007). Child Health 10.154 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR RINGWORM: NON-HAIRY SKIN (Tinea corporis) DEFINITION Superficial fungal infection involving the face, trunk or limbs. ETIOLOGY Several different fungi. Transmitted by direct contact with an infected person, lesions, animals, or contaminated articles. SUBJECTIVE Condition is asymptomatic or client has mild itching of the skin. OBJECTIVE 1. Erythematous scaling patches (usually 1-2) that are round or oval. The lesions start small, then expand outward with clearing of the eruption in the center of the patch and activity restricted to the border of the lesion, as a ring. The border of the lesion is usually raised and scaly but may include small pustules or vesicles. Mildly pruritic. 2. Lesions are most common on the trunk, face, and arms. ASSESSMENT Tinea corporis (Ringworm of the skin) PLAN THERAPEUTIC PHARMACOLOGIC If thickening of the skin has occurred, apply a nonprescription topical anti-fungal preparation. Wash the lesion with soap and water and dry it thoroughly before applying the medication. May choose one of the following: 1. Tolnaftate 1% (e.g., Tinactin), cream or solution. Apply to affected areas twice daily for 4 weeks. OR 2. Miconazole nitrate 2% (e.g., Micatin), cream. Apply to affected areas twice daily for 4 weeks. (Not for OTC use in children < 2 years.) OR 3. Clotrimazole 1% (e.g., Lotrimin, available as Lotrimin AF, cream or solution). Apply to affected areas twice daily for 4 weeks. Child Health 10.155 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 CLIENT EDUCATION/COUNSELING 1. Investigate contacts and sources of infection and promote treatment, as appropriate. 2. Recommend effective and frequent laundering of clothing. 3. Children with lesions should not be excluded from the classroom as long as clothing or a light bandage covers the lesions. 4. It is important to apply the topical antifungal for 4 weeks, even if the rash clears in less than 4 weeks, to prevent recurrence. REFERRAL 1. Severe or widespread infection. 2. Secondary bacterial infection. 3. Failure to respond to treatment. Several skin conditions can closely mimic ringworm, these include: granuloma annulare, nummular eczema, erythema chronicum migrans, and early Lyme disease. 4. If there has been tick exposure, refer immediately. Early Lyme disease is an urgent diagnosis. REFERENCES 1. 2. 3. 4. 5. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) American Academy of Pediatrics, Red Book: Report of the Committee on Infectious Diseases, 27th ed., 2006, pp. 656-657. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, pp. 3465-3468, 3472-3474, 3494. Lexi-Drugs OnlineTM, Lexi-Comp DatabaseTM, Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24 , 2007) Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 <http://online.factsandcomparisons.com>. Child Health 10.156 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR RINGWORM: SCALP (Tinea Capitis) DEFINITION Fungal infection of the scalp and hair follicles, primarily seen in children before puberty. ETIOLOGY Fungal infection from humans or animals. Spread by direct personal contact with an infected person. SUBJECTIVE 1. Itching usually occurs in affected areas. 2. Ask if Blue Star ointment is being used (if using, will not be effective against ringworm). 1. Lesions usually develop in single or multiple patches in the occipital, temporal and parietal areas of the scalp. 2. Lesion appear as patches, rounded or oval in outline, covered by scales and lusterless, irregularly broken hairs. If broken hairs not present, consider trichotillomania (chronic hair pulling), or alopecia areata. 3. Boggy, raised and suppurative lesions, called kerion, may be present. 4. Under a Wood’s light the filtered, ultraviolet radiation causes Microsporum infections to fluoresce with a brilliant yellow-green light. Currently, more than 90% of cases are caused by Trichophyton tonsurans which does not fluoresce. OBJECTIVE ASSESSMENT Tinea capitis (Scalp ringworm) PLAN THERAPEUTIC PHARMACOLOGIC Griseofulvin - Do not give if client is pregnant or has liver problems. 1. Child > 2 years: Griseofulvin microsize, or 125 mg/5 mL suspension, 15-20 mg/kg/day (maximum 1 gram/day) PO once daily for 8-12 weeks, OR Child Health 10.157 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 2. Until 2 wks after complete resolution. (If > 12 wks refer to physician for consideration of another antifungal medication.) OR If at least 2 years of age: Griseofulvin ultramicrosize, 5-10 mg/kg/day (maximum 750 mg/day) PO, either in 2 divided doses OR Once daily, with milk or ice cream, for 8-12 weeks; OR Until 2 wks after complete resolution. (If > 12 wks refer to physician for consideration of another antifungal medication.) Griseofulvin Weight Dosage (microsize) (susp. 125mg/5mL) Dosage (ultramicrosize) 30-49 lbs 125-250 mg/day 82.5-165 mg/day >50 lbs 250-500 mg/day 165-330 mg/day NOTE: Griseofulvin decreases the effect of oral contraceptives; it may alter theophylline clearance, and blood concentrations of cyclosporine. Do not give with barbiturates. Do liver function tests after 1 week of therapy. Do not use with alcohol. Alcohol use may cause a disulfiram reaction. NON-PHARMACOLOGIC Wash hair daily to help remove loose hair. CLIENT EDUCATION/COUNSELING 1. Griseofulvin may cause nausea, vomiting, diarrhea and epigastric pain. Report symptoms of toxicity (allergic rash/urticaria, insomnia, or paresthesia). Photosensitivity may occur: advise client to avoid prolonged exposure to strong sunlight. 2. All infected household members should be treated. 3. Use Nizoral shampoo to decrease fungal shedding. (Include all family members – they may be “carriers” but not have active disease.) Child Health 10.158 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 4. Wash brushes and combs; discourage sharing. 5. New hair growth is slow and may take 3 to 6 months. 6. If applicable, client should be informed to wait to father a child for at least 6 months after completion of griseofulvin therapy. Females should be informed to avoid becoming pregnant while taking griseofulvin. 7. Emphasize the importance of strict compliance – daily for up to 12 weeks as needed. Failure is frequent because of poor compliance. The result can be permanent scarring of the scalp. In one study only 17% of patients used griseofulvin for 6 wks or more as directed. REFERRAL 1. Secondary bacterial infection or kerion. (A kerion is also treated with griseofulvin; however, oral or injected steroids are also frequently used to reduce scarring.) 2. No response to griseofulvin, side or toxic effects, or worsening of condition after treatment has started. 3. Less than 2 years of age. 4. Pregnant. 5. History of liver problems. REFERENCES 1. 2. 3. 4. 5. 6. 7. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, pp. 532-534. Tuan Dang Nguyen, “Ringworm, Scalp,” eMedicine, September 18, 2007. Grace F. Kao, “Tinea Capitis,” e-Medicine, January 17, 2002. (Current) Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24 , 2007) Sarah Long, Principles and Practice of Pediatric Infectious Disease, 2nd ed., Elsevier, 2003. (Current) Dong-Churl Suh, et al., Tinea Capitis in the United States: diagnoses, treatment and costs, Journal of the American Academy of Dermatology, 2006, Volume 55, pp. 1111-2. Child Health 10.159 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR ROSEOLA (EXANTHEMA SUBITUM) DEFINITION Roseola is the most common acute febrile exanthem of children ages 6 months to 2 years. The rash phase generally occurs in conjunction with the disappearance of fever. Cases usually occur sporadically throughout the year. Infection in children less than 3 months and over 3 years is uncommon. There is no distinct seasonal pattern. Roseola has the ability to mimic other, more serious, treatable diseases, such as pneumococcal sepsis and bacterial meningitis. ETIOLOGY Human herpes virus type 6. The incubation period is 9-10 days. SUBJECTIVE 1. Sustained high fever 3-5 days before rash appeared. 2. Irritability, malaise. 3. Runny nose. 1. Pale rose-pink macules, surrounded by a halo, over neck and trunk. 2. Fever may be gone when rash becomes apparent. 3. Lymphadenopathy. 4. Eyelid swelling, “sleepy-eyed” appearance. 5. Red throat with small lesions on palate or tonsils. OBJECTIVE ASSESSMENT Exanthema subitum (roseola) (Based on non-specific rubelliform eruption, following three to five days of spiking high fever in a young child.) PLAN THERAPEUTIC The treatment is supportive. CLIENT EDUCATION/COUNSELING 1. Children with febrile exanthema should not return to a child-care or preschool setting until the rash is gone and they are well. 2. Exposure to pregnant females does not pose a risk. Child Health 10.160 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 FOLLOW-UP/REFERRAL Febrile seizures and other neurological manifestations of roseola may require further evaluation. REFERENCES 1. 2. Leigh B. Grossman, Infection Control in the Child Care Center and Preschool, 6th ed., Lippincott Williams & Wilkins, Baltimore, MD, 2003. (Current) American Academy of Pediatrics, Red Book: Report on the Committee on Infectious Diseases, 27th ed., 2006. Child Health 10.161 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR RUBELLA DEFINITION Rubella is usually a mild disease in children, commonly inapparent and unrecognized, but the illness is often more severe among adolescents and adults. Transient arthralgia and polyarthritis occasionally occur in children and are common in adolescents and adults. The incidence of rubella in the United States has declined by approximately 99% from the prevaccine era. Unvaccinated children are at risk of developing rubella if exposed. Infants who contract rubella in utero often exhibit congenital rubella syndrome with ophthalmic, cardiac, auditory, and neurologic disorders with mental retardation. Mild forms of the disease can be associated with few or no obvious clinical manifestations at birth. ETIOLOGY Rubella virus (family Togaviridae; genus Rubivirus). The incubation period ranges from 14-21 days, usually 16-18 days. SUBJECTIVE 1. Rash, appearing first on face, and spreading downward and peripherally. 2. May report no prodromal symptoms, or mild lethargy, anorexia, and upper respiratory symptoms. 3. Older children may have mild arthritic complaints. 1. Pink maculo-papular rash that begins on the face and neck and spreads to the trunk and extremities. Usually disappears by the third day. 2. Low-grade or no fever during the period of the rash. 3. Lymphadenopathy noted in the suboccipital, postauricular, and cervical areas. 4. The virus may be isolated from nasopharyngeal secretions from 7 days before to 7 days after onset of rash. (Isolation of the virus from blood, urine, spinal fluid can occur up to one year of age for congenitally-infected infants.) OBJECTIVE ASSESSMENT Rubella (may be in a mild form with few or no clinical manifestations) Child Health 10.162 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 PLAN Immediately report all cases of rubella to the State Notifiable Disease Unit. (Refer to the Surveillance and Reporting section of the Immunization Program Manual.) DIAGNOSTIC Serologic testing to determine immune status is recommended for all pregnant women exposed to rubella. THERAPEUTIC 1. Supportive treatment. 2. Prevention: a. One dose of rubella vaccine is currently recommended for all persons born after 1956 and for all women who could become pregnant. Special emphasis must continue to be placed on immunization of postpubertal males and females, especially college students, military recruits, and health-care workers/child-care workers. Post-pubertal females without documentation or presumptive evidence or immunization should be immunized unless they are known to be pregnant, and should be warned not to become pregnant for 4 weeks. It is usually administered in combination with measles and mumps vaccine (MMR) when a child is 12-15 months of age and then again at 4-6 years of age. See the Immunization Program manual for more specific administration guidelines. The Georgia Immunization Manual may be accessed on line at http://health.state.ga.us/publications/manuals.asp. b. The use of immune globulin is not routinely recommended for post-exposure prophylaxis in early pregnancy or any other circumstance. c. For persons > 12 months of age, vaccination with rubella vaccine after exposure is recommended for susceptible persons if no contraindications exist. The vaccination may not prevent disease, but it will provide protection against subsequent exposures. d. Consult with the State Notifiable Disease Unit for all suspect cases and contacts (404-657-2588). Child Health 10.163 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 CLIENT EDUCATION/COUNSELING 1. Individuals are often contagious up to one week before and at least 4 days after the onset of the rash. 2. Infants with congenital rubella should be considered contagious until they are 1 year of age, unless cultures are negative. 3. Children with rubella should be excluded from school or child-care for 5-7 days after onset of rash. 4. Documentation of protection either by date of immunization or positive serology is required for children attending school or daycare. In the event of exposure to a case, immunized children are unlikely to develop the disease and may continue to attend school. CONSULT/REFERRAL 1. If the individual has received immune globulin or a blood product within the preceding 3 months it may interfere with the immune response of the vaccine. Determine the appropriate course of action and interval that may be required to ensure an adequate immune response to the vaccine. 2. If pregnant or attempting to become pregnant. REFERENCES 1. 2. 3. 4. 5. 6. 7. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) Leigh B. Grossman, Infection Control in the Child Care Center and Preschool, 6th ed., Lippincott Williams and Wilkins, Baltimore, MD, 2003. (Current) American Academy of Pediatrics, Red Book: Report of the Committee on Infectious Diseases, 27th ed., Elk Grove Village, IL, 2006. American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, pp. 3416-3423. “Revised ACIP Recommendation for Avoiding Pregnancy After Receiving a RubellaContaining Vaccine,” MMWR, Vol. 50, No.49, July 13, 2001, p1117. (Current) “Measles, Mumps, and Rubella- Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella syndrome and Control of Mumps,” MMWR, Vol.47, No. RR-8, May 22, 1998. (Current) David L. Heymann, Editor, Control of Communicable Diseases Manual, 18th ed., Washington, DC, American Public Health Association, 2004, p. 468. (Current) Child Health 10.164 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR MEASLES/RUBEOLA DEFINITION Measles is an acute illness characterized by fever, cough, coryza, conjunctivitis, an erythematous maculopapular rash, and a pathognomonic enanthem (Koplik spots). It is transmitted by direct contact. The peak incidence usually occurs during winter and spring. The childhood immunization program in the United States has resulted in a greater than 99% reduction in the reported incidence of measles. A single case of measles is considered a public health emergency. ETIOLOGY Measles virus is an RNA virus with one serotype. The incubation period is generally 8-12 days. SUBJECTIVE 1. 2. 3. 4. 5. 6. OBJECTIVE 1. 2. 3. 4. ASSESSMENT Sudden onset of fever as high as 106oF (41.1oC). Fever may fall as the rash appears. Marked coryza (nasal discharge), conjunctivitis, and cough followed by a generalized maculopapular rash. Rash appears after other symptoms. May report seeing Koplik spots (small whitish specks on a red base that appear on the buccal mucosa) in the mouth. Marked malaise, headache, myalgia, and anorexia. May report vomiting and diarrhea. Ask for history of measles immunization(s). Koplik spots are pathognomonic, and may be present two days before the onset of the rash. Maculopapular darkly erythematous rash begins at the hairline and spreads to the face descending to the trunk and extremities in a downward and outward pattern. The rash often becomes confluent on the face and upper trunk. It disappears in the same order as it appeared, fading from the face first, then the trunk and extremities. May have lymphadenopathy and slight splenomegaly as symptoms become more severe. Serologic identification of immunoglobulin M (IgM) measles antibody. Measles/rubeola Confirmation should be made by IgM antibody testing. Measles IgM antibody may be negative if collected in the first 72 hours of illness; therefore, repeat testing may be required. Child Health 10.165 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 PLAN Assess measles immunization status (99%, but not 100%, effective). Immediately report all suspect or confirmed cases of measles to the State Notifiable Disease Unit. Refer to the Surveillance and Reporting section of the Immunization Program Manual. THERAPEUTIC 1. Supportive treatment. 2. Prevention. a. Two doses of the live attenuated measles vaccine are routinely recommended for all persons born after 1956 and for all persons born prior to 1956 who lack documentation of vaccination or proof of the disease. 1) The measles vaccine is usually administered in combination with the rubella and mumps vaccines. 2) First dose of vaccine is recommended to be administered at 12-15 months of age and a second dose at 4-6 years of age. However, the 2nd dose may be given earlier, provided at least 4 weeks have lapsed since first dose. 3) Do not administer to pregnant women and advise women not to become pregnant for 4 weeks after vaccination. 4) See Immunization Program Manual for more specific administration guidelines. The Georgia Immunization Manual may be accessed on line at http://health.state.ga.us/publications/manuals.asp. b. Live measles vaccine provides permanent protection and may prevent disease if given within 72 hours of exposure. Infants as young as 6 months of age may be given measles vaccine (monovalent if available) in the outbreak setting and before travel to a foreign country where measles is endemic. However, doses of MMR administered before 1 year of age should not be counted. Any child receiving vaccine before 1 year of age should be re-vaccinated at 12-15 months of age, with an additional dose at 4-6 years of age. Doses of any measles containing vaccine should be separated by a minimum of 4 weeks or 28 days. Child Health 10.166 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 c. Administration of Immune Globulin (IG) to certain susceptible household contacts who were not vaccinated within 72 hours of initial exposure is recommended, especially those under 12 months of age, pregnant women and immunocompromised individuals. Those who receive Immune Globulin (IG) for post-exposure prophylaxis should receive immunizations containing the measles virus vaccine, initiated 5 months after IG, provided the individual is at least 12 months of age and has no contraindications. IG should not be used to control measles outbreaks. d. Susceptible non-household contacts should be vaccinated after exposure even if it is past 72 hours. If exposure to the disease does not cause an infection, post-exposure vaccination with measles vaccine (MMR) should induce protection against subsequent infections. e. Consult with the State Notifiable Disease Unit for all suspect cases and contacts. (404-657-2588) CLIENT EDUCATION/COUNSELING 1. Children should be kept out of school/child-care until at least 4 days after appearance of rash and child has no fever. 2. Parents of children in a school or child-care center in which measles has occurred should be immediately notified and should contact their physician right away. Susceptible children who fail to receive preventive therapy will have to be excluded from school or child-care until the risk of spread is over (21 days from the onset of the last case). 3. Common complications, which include pneumonia, otitis media, diarrhea and encephalitis, require medical intervention. CONSULT/REFERRAL 1. All children with suspected rubeola should be referred to a physician for follow-up and consideration of Vitamin A therapy. Parents should be advised to call their provider immediately for an appointment time and place to avoid exposing other persons or patients. 2. If the individual has received Immune Globulin or a blood product within the preceding 3 months, it may interfere with the immune Child Health 10.167 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 response of the vaccine. Refer to “General Recommendations on Immunization,” MMWR, Vol.55, No. RR-15, December 1, 2006, p. 8. Determine the appropriate course of action and interval that may be required to ensure an adequate immune response to the vaccine. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) Leigh B. Grossman, Infection Control in the Child Care Center and Preschool, 6th ed., Lippincott Williams & Wilkins, Baltimore, MD, 2003. (Current) American Academy of Pediatrics, Red Book: Report of the Committee on Infectious Diseases, 26th ed., Elk Grove Village, IL, 2006. (Current) American Society of Health-Systems Pharmacists, American Hospital Formulary Service, 2007, pp. 3299-3311,3416-3422. “General Recommendations on Immunization,” MMWR, December 1, 2006, Vol. 55, No. RR-15, p. 8. “Measles, Mumps, and Rubella- Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella syndrome and Control of Mumps,” MMWR, Vol.47/ NO. RR-8, May 22, 1998. (Current) CDC, Epidemiology & Prevention of Vaccine-Preventable Disease, 10th ed., Atlanta, GA, January 2007, pp. 138-142. CDC, Manual for the Surveillance of Vaccine-Preventable Diseases, 3rd ed., Atlanta, GA, 2002, Chapter 6, Measles: p.16. (Current) Child Health 10.168 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR RUBRAL/HEAT RASH DEFINITION Heat rash ("prickly heat”) is characterized by an erythematous papular rash, distributed in areas where sweat glands are concentrated. Obstruction of the eccrine sweat ducts occurs often in neonates and often produces one or two clinical pictures depending on the level of obstruction: 1. Miliaria crystallina is characterized by tiny (1-2 mm), superficial grouped vesicles, without erythema, over intertriginous areas and adjacent skin (neck, upper chest). Obstruction occurs in the statum corneum portion of the eccrine duct. 2. Miliaria rubra is more common. Obstruction of the eccrine duct deeper in the epidermis results in erythematous, grouped papules in the same area. Rarely, these may progress to pustules. ETIOLOGY This rash results from obstruction of the ducts of the sweat glands. The ducts become distended and break, leaking sweat into the skin, which causes the irritation. Heat and high humidity in the external environment cause sweating that leads to swelling and plugging of the sweat gland orifice. SUBJECTIVE 1. Parent notices fine, red raised rash on child; may see pustules under neck and armpits. 2. Itching. 3. History of over-dressing. 4. History of predisposing environmental factors (e.g., hot spells in summer or house kept too warm). 1. Rash is erythematous and vesiculopapular. Lesions are pinhead size and may coalesce on an erythematous patch or remain isolated. The sudden appearance of red patches of small papules and/or vesicles are discrete and accompanied by red areolae. 2. Rash is distributed in areas of sweat gland concentration and friction: over the trunk, neck, back of head, shoulders, chest, axillae, face, antecubital and popliteal fossae, and intertriginal areas. OBJECTIVE ASSESSMENT Rubral/heat rash, according to lesion appearance and history (hot, humid environment). Differentiate from: contact dermatitis (history of contact, distribution in Child Health 10.169 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 area of contact, edematous, erythematous and vesicular lesions) or candidiasis (shiny, intensely inflamed, sharply-defined border, and satellite lesions). PLAN THERAPEUTIC PHARMACOLOGIC May apply nonprescription 1% hydrocortisone cream three times a day for severe inflammation. NON-PHARMACOLOGIC 1. Keep the environment cool and dry; use air conditioner, fan and/or dehumidifier, if possible. 2. Keep skin clean and dry. 3. Tepid or cool baths; may use 1/2 cup baking soda or oatmeal in bath. 4. Avoid overdressing the child. The parent should dress the child as she/he would dress self for weather conditions. CLIENT EDUCATION/COUNSELING 1. Use hydrocortisone cream sparingly. 2. Use mild or hypoallergenic soap (Neutrogena or Lowila). 3. Avoid harsh detergents, bleach and fabric softener. 4. Keep baby’s fingernails short. 5. If rash is on the back of the neck, advise mother not to wear irritating clothing when feeding baby. 6. Do not put baby to sleep in the sun. REFERRAL 1. If there is no improvement with treatment. 2. Exacerbation of the rash. Child Health 10.170 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 REFERENCES 1. 2. 3. Rose W. Boynton et al., Manual of Ambulatory Pediatrics, 5th ed., Lippincott Williams & Wilkins, Philadelphia, PA, 2003. (Current) William W. Hay, et al., Current Pediatric Diagnosis and Treatment, 16th ed., McGrawHill, 2003. (Current) Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) Child Health 10.171 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR SCABIES DEFINITION Infestation with the Sarcoptes scabiei mite. The initial skin lesion is a burrow made by an impregnated female to lay her eggs. It appears as a fine, wavy, dark line boring from a few mm to 1 cm in length, with a minute papule at the open end. (Papules or vesicles contain the mite.) After several days, sensitivity to the mite results in pruritis followed by punctate excoriations from scratching and impetiginous and eczematous changes at the site of the lesion. A generalized urticarial rash may also develop. The condition is highly contagious and is spread by skin-to-skin contact and contact with contaminated clothing or linens. Transmission to household members and sexual contacts is frequent. Outbreaks in schools, day care centers and nursing homes have occurred. ETIOLOGY The Sarcoptes scabiei mite. The female is about 0.44 mm long and has 4 sets of legs. The male is about half her size. Fertilization occurs on the skin surface. The male dies 1-2 days after copulating. The impregnated female burrows into the stratus corneum and lays 1-3 eggs daily throughout her 30-day life cycle. (She can survive only 2 or 3 days away from the warm skin.) The eggs hatch in 3-5 days and the larvae return to the skin to grow, molt and mature. Fortunately, fewer than 10% of the eggs laid by a mite develop into adult mites. SUBJECTIVE 1. Intense itching, most severe at night. 2. Rash. 3. May have history of known exposure to scabies, or of several family/group members having a similar itchy rash. 1. Observation of burrows and red papular vesicles or pustules, distributed according to age: OBJECTIVE a. b. Infants. The palms, soles, neck, face, scalp, legs and buttocks are commonly affected. Burrows are absent and vesicles, pustules, bullae and eczematous lesions are common. Older children, adolescents and adults. The lesions begin in the interdigital spaces and spread to the wrist, elbows, ankles, buttocks, umibilicus, belt line, groin, genitalia, areola, female breast and axillae. The upper back, neck, face, scalp, palms and soles are usually spared. Child Health 10.172 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 2. Red, itchy rash, pustules and excoriation. 3. Secondary infection from scratching. NOTE: Atypical forms of scabies do occur and can be related to such things as personal hygiene, by the presence of another skin disease or in altered immunologic response in patients suffering from malnutrition, or other neurologic or physical disorders/diseases (Norwegian scabies). ASSESSMENT Scabies, based on history and suspicious lesions. (With appearance varying, differential diagnosis depends on the type of lesion present. Papulovesicular lesions can appear similar to papular uritcaria, chicken pox, drug eruptions, canine scabies, viral exanthems, dermatitis herpetiform, and folliculitis. If the lesions are eczematous, atopic dermatitis and seborrheic dermatitis must be ruled out. Nodular scabies may be misdiagnosed as urticaria pigmentosa, histeocytosis and insect bite granuloma.) Confirmatory diagnosis can be made microscopically. PLAN DIAGNOSTIC STUDIES Microscopic visualization of the mite. The suspected lesion is immobilized between the forefinger and the thumb and the top is removed with a Number 15 scalpel blade laid parallel to the skin surface. No anesthesia is required. The specimen is then placed on a glass slide, covered with a drop of immersion oil and a cover-slip, and then examined under low power for the mite, eggs or larvae. THERAPEUTIC PHARMACOLOGIC 1. Permethrin 5% Cream (Elimite) single application for children 2 months or older. Do not bathe or shower before applying the cream. Thoroughly massage into all skin from the neck down to the soles of the feet, avoiding contact with mucous membranes, eyes and mouth. Also include the head, scalp and neck in infants and toddlers. Remove by washing after 8-14 hours. (Thirty grams or half of a 60gram tube should be sufficient for a child.) May repeat permethrin treatment once in 7 days. 2. Second-line Treatment – Only if treatment with permethrin fails and client is at least 4 years old, not pregnant or lactating, weighs at least 110 pounds and does not have uncontrolled seizures, or extensive dertmatitis: Lindane Child Health 10.173 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 lotion. Apply in thin layer from neck downward. Avoid face, urethral meatus, and mucous membranes. Should not apply after bath/shower, wait at least 1 hour after a bath/shower, the skin should not be wet. For children 4-11 years, rinse off skin completely with warm (not hot) water after 6-8 hours; for adults and children at least 12 years old, rinse off completely with warm (not hot) water after 812 hours. Do not repeat. Do not provide more than 60mL. A Lindane Medication Use Guide must be given to all patients along with instructions for proper use. 3. Cool baths with mild soap, nonprescription hydrocortisone cream topically or diphenhydramine (e.g., Benadryl) orally for itching, which may persist for several weeks. 4. Prophylactically treat (with permethrin) all household members and/or caretakers who have prolonged skin-toskin contact, at the same time as the index case. CLIENT EDUCATION/COUNSELING 1. Name of condition and clear directions for treatment. 2. Keep fingernails clean and well-trimmed. 3. Launder all bedding, towels, wash cloths and solid clothing that have been in contact with the patient for the 4 days prior to treatment. Laundering should be done in hot water and drying in the hot cycle of the clothes dryer. Commercial dryers are recommended because the temperature is hotter than household dryers. If washing/drying is not possible, store the items in a plastic bag for a week to avoid re-infestation. 4. Encourage to wash hands often, shampoo hair frequently, wear clean clothes daily and not to exchange clothes with others. 5. Elimite may temporarily increase itching, edema and redness. Mild and transient stinging and/or burning of the skin may also occur. These reactions are associated with the severity of the infestation. 6. Children should be allowed to return to school or child-care after treatment has been completed (24 hours). Itching may continue for several days after effective treatment. This is a hypersensitivity response and does not mean that the child can spread the infection to others. Child Health 10.174 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 7. Disinfecting the environment is unnecessary and unwarranted. 8. Close contacts need prophylactic treatment because manifestations of scabies infestation may not appear for as long as 2 months after exposure, during which time they can be transmitted. FOLLOW-UP 1. Re-examine in one week. May re-treat once if no improvement, though single application of permethrin 5% cream is usually curative. 2. A client symptomatic longer than 4 weeks after treatment should be re-evaluated for possible re-exposure. REFERRAL 1. Severe/widespread infection, or secondary bacterial infection. 2. Infection of the scalp (usually infants). 3. Any of the following: a. < 2 months of age. b. Pregnant or lactating. c. Failure to respond to 2 rounds of permethrin AND either < 110 lbs or pregnant/possibly pregnant/or at risk to become pregnant in next 14 days. 4. Failure to respond to 2 rounds of permethrin treatment and one round of lindane (if lindane not contraindicated). Child Health 10.175 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 REFERENCES 1. 2. 3. 4. 5. 6. 7. Axalla J. Hoole et al., Patient Care Guidelines for Nurse Practitioners, 5th ed., Lippincott Williams & Wilkins, 1999. (Current) William W. Hay et al., Current Pediatric Diagnosis & Treatment, 16th ed., McGraw-Hill, 2003. (Current) Constance R. Uphold, and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books Inc., Gainesville, FL, 2003. (Current) American Society of Health-Systems Pharmacists, American Hospital Formulary Service, Bethesda, MD, 2007, pp.3499-3502. Lexi-Drugs OnlineTM, “Lexi-Comp Database”TM, Lexi-Comp, Inc., Hudson, Ohio, 2007, <http://www.online.lexi.com/crisql> (April 24 , 2007) Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 <http://online.factsandcomparisons.com>. E Leonard et al., Ectoparasitic Infections, Clin Fam Pract, 2005, 7:97-104. Child Health 10.176 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR STYE (EXTERNAL HORDEOLUM) DEFINITION An abscess of the sebaceous (meiobian) gland of the eyelash follicle at the lid margin. It is generally unilateral. ETIOLOGY Staphylcoccus aureus. SUBJECTIVE 1. Inflammation, tenderness and swelling of the eyelid margin. 2. May complain of a bump or pimple on eyelid. 3. No reported decrease in visual acuity. 1. Erythema and edema at eyelid margin. A palpable nodule is usually present. 2. Purulent drainage as a result of spontaneous rupture of the abscess. 3. May complain of eyelid pain and tenderness, but no complaint of eye pain. 4. No decreased visual acuity, abnormal pupils, or photophobia. OBJECTIVE ASSESSMENT External Hordeolum (Stye) PLAN DIAGNOSTIC STUDIES Assess visual acuity. (Child with a refraction error may rub eyes repeatedly.) THERAPEUTIC PHARMACOLOGIC Refer to MD/NP urgently for antibiotic treatment if cellulitis of the lid is present. NON-PHARMACOLOGIC Warm, moist compresses for 15-20 minutes every 2-3 hours. Child Health 10.177 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 CLIENT EDUCATION/COUNSELING 1. For moist compresses, use a soft cloth and water as warm as child can tolerate. 2. Use thorough hand washing technique after soaks and instillation of medication, if prescribed, to prevent spread. 3. Keep fingers away from eyes. 4. Never squeeze a stye. 5. Advise teens to avoid use of eye makeup until condition is resolved and discard all old makeup that may be contaminated. REFERRAL 1. For antibiotic treatment, if cellulitis of lid is present beyond lid margin. 2. If lesion is well-localized and not draining, to assess need for incision and drainage. 3. No response to treatment in 48 hours. 4. Lesion not resolved after 6 days. 5. Recurrent site: may indicate immunological deficit or systemic disease (e.g., diabetes). REFERENCES 1. 2. 3. 4. Constance R. Uphold and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Gainesville, FL, 2003. (Current) Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) Carol D. Berkowitz, Pediatrics: A Primary Care Approach, 2nd ed., W.B. Saunders, 2000, pp. 245, 247. (Current) Naradzay J, Baris R, Approach to Ophthalmologic Emergencies, Medical Clinics of North America, 2006, 90-305-328. Child Health 10.178 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR TEETHING DEFINITION Inflammation of the gum tissue caused by eruption of primary teeth. ETIOLOGY In general, an infant’s first tooth erupts at 6 months and one each month thereafter until all 20 have erupted. However, this is highly variable from child to child. One child might begin teething as early as 3 months, while another would not begin until age 12 months. The central lower incisors are usually the first to erupt. SUBJECTIVE 1. The infant may be cross and fretful. 2. The infant may have decreased appetite. 3. The infant may suck his fist, fingers or anything else he can get into his mouth, more than usual. 4. Some parents report increased drooling, but this is more likely due to the infant’s inability to control salivation. 1. The first sign of teething may be when the parent feels the erupting tooth with a finger or hears it click against a spoon. 2. Diarrhea and fever are generally not associated with teething. (The primary care provider should be consulted if they occur.) OBJECTIVE ASSESSMENT Teething PLAN THERAPEUTIC PHARMACOLOGIC 1. Systemic analgesia (acetaminophen or ibuprofen) in appropriate doses. (One to 2 doses/day maximum, preferably before feeding.) (Ibuprofen preferred for teething if infant > 6 mos.) 2. Avoid topical anesthetics (teething gels). They can cause profound numbness of the entire oral cavity and pharynx and suppress the gag reflex. They can also induce allergies to ‘caine’ anesthetics. Child Health 10.179 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NON-PHARMACOLOGIC 1. Be patient and soothe the infant. 2. Offer a child Zwieback or hard toast. Offer an infant a teething ring of hard rubber or plastic, or a clean, cold, wet washcloth for chewing on. PARENT EDUCATION/COUNSELING 1. Counsel about the above therapeutic measures. 2. Be sure that the infant/child does not chew on things that would break or splinter in the mouth. REFERRAL Eruption cysts or hematomas. REFERENCES 1. 2. 3. William W. Hay et al, Current Pediatric Diagnosis and Treatment, 16th ed., McGrawHill, 2003. (Current) Carol D. Berkowitz, Pediatrics: A Primary Care Approach, 2nd ed., W.B. Saunders, 2000, pp. 245-247. (Current) Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) Child Health 10.180 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR THRUSH (ORAL CANDIDIASIS) DEFINITION Superficial fungal infection of the mouth, frequently occurring in healthy newborns. It is rare in older children and adults except those who are debilitated or receiving antibiotic or immuno-suppression therapy. ETIOLOGY The causative organism is usually Candida albicans, which is acquired from the following sources: 1. 2. 3. 4. 5. SUBJECTIVE OBJECTIVE ASSESSMENT In newborns, from mother’s vagina during birth. Persons that may be debilitated and those receiving antibiotic therapy. By contamination of caretaker’s hands or objects shared by babies. Adult with vulvovaginal candidiasis, through contamination of her hands. (See protocol for vulvovaginal candidiasis.) Infants/children with candidal diaper dermatitis, through contamination of hands. 1. Often no symptoms. 2. Creamy white patches in the mouth, may be curd-like in nature. 3. With extensive involvement, pain during feeding and swallowing. 4. May have history of recent steroid, antibiotic or chemotherapy treatment. 1. White flaky coating or patches covering all or part of the tongue, gingiva, buccal mucosa and, occasionally, the lips. (Don’t confuse with milk curds left on the tongue after feeding.) 2. If patches are removed, they leave a painful, red bleeding lesion. 3. The patient may have candidal diaper dermatitis that needs treatment. 4. May have an inadequate oral intake because of mouth pain. Check for dehydration (uncommon). Oral Candidiasis (Thrush) Child Health 10.181 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 PLAN DIAGNOSTIC STUDIES Potassium hydroxide preparation of scrapings of lesions to detect budding yeast, with or without hyphae. (This study is usually not needed when typical lesions are present.) THERAPEUTIC PHARMACOLOGIC 1. Treatment of infant: Nystatin (Mycostatin) oral suspension,100,000 units/mL, to use in a dosage of 200,000 units (2 mL) four (4) times a day for two weeks. The dose should be divided so that ½ is placed in each side of the mouth. The suspension should be retained in the mouth for as long as possible. One way to accomplish this is to apply a portion of the dose to two Q-tips and gently massage these Q-tips against the plaques. Low birth-weight infants should receive a dose of 100,000 units (1 mL) four (4) times daily. 2. Treatment of nursing mother: Nystatin (similar to Mycostatin) ointment applied to nipple and areola areas after each feeding OR Nystatin oral suspension 100,000units/mL; swab 1 mL on each breast nipple four times daily after feeding, for 2 weeks. 3. If diaper rash is present, treat according to Nurse Protocol for Diaper Dermatitis due to candidiasis. CLIENT EDUCATION/COUNSELING 1. Continue treatment for two weeks, even if the mouth appears to have cleared before the fourteenth day. 2. Properly treated, thrush should not be a cause for weaning from the breast. 3. Breast-fed infants and their mothers are to be treated simultaneously. 4. Wash hands thoroughly before handling any baby. Child Health 10.182 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 5. Rubber/plastic nipples and pacifiers should be boiled for 10 minutes, or replaced after beginning treatment. Do not allow infants to share pacifiers or nipples. REFERRAL 1. Failure to respond after two weeks of therapy. 2. Weight loss, or suspected dehydration. 3. Recurrent or resistant breast infections. 4. Persons with recurrent infections are to be evaluated for HIV infection. REFERENCES 1. 2. 3. 4. 5. Ruth Lawrence, Breast-Feeding: A Guide for the Medical Profession, 5th ed., C.V. Mosby Co., 1998. (Current) Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2003. (Current) Carol D. Berkowitz, Pediatrics: A Primary Care Approach, 2nd ed., W.B. Saunders, 2000, pp. 213, 215, 230, 459. (Current) American Society of Health-Systems Pharmacists, American Hospital Formulary Services, Bethesda, MD, 2007, p.3491-3494. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 <http://online.factsandcomparisons.com>. Child Health 10.183 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR TINEA PEDIS DEFINITION Dermatophyte infections of the skin of the feet and toes. ETIOLOGY Trichophyton rubrum is the most common pathogen. Trichophyton mentagrophytes causes more inflammatory lesions. The fungus is transmitted by direct contact with contaminated surfaces in moist areas such as swimming pools, community showers or baths and locker rooms. Tinea pedis occurs most frequently in adolescents and adults. Risk factors include sweaty feet and occlusive footwear. SUBJECTIVE OBJECTIVE 1. May be asymptomatic. 2. Mild itching. 3. May have burning, stinging and other sensations. 1. On the sole and heel: usually non-inflammatory scaling, occasionally with thickening and cracking of the skin. May have groups of vesicles or exfoliation of the skin. Foul odor is common. 2. Between the toes: scaling or fissuring, fine vesicles or pustules, maceration. 3. Potassium hydroxide (KOH) skin-scraping: hyphae demonstrated (more likely to find from dry scaly areas than from wet, macerated areas). ASSESSMENT Tinea pedis PLAN THERAPEUTIC PHARMACOLOGIC 1. One of the following products. Continue treatment for 1-2 weeks after clinically cleared. a. Over-the-counter products, applied bid for 2-4 weeks to the affected areas. 1) Miconazole (e.g., Micatin) 2% cream OR 2) Clotrimazole (e.g., Lotrimin, Mycelex) 1% solution, cream or lotion Child Health 10.184 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 3) OR Tolnaftate 1% (e.g., Tinactin) OR b. 2. Prescription products 1) Ketoconazole 2% cream (e.g., Nizoral) Apply once daily for 6 weeks. 2) Econazole 1% cream (e.g. Spectazole) Apply once daily for 4-6 weeks. Burrow’s solution may be used as a foot soak, 20-30 minutes bid, for lesions between the toes. CLIENT EDUCATION/COUNSELING 1. Wear rubber or wooden sandals in community showers and locker rooms. 2. Wash the feet with a benzoyl peroxide bar after showering. 3. Carefully dry between the toes after bathing/showering. A hair dryer on low setting may be used after toweling dry. 4. Change socks frequently. Avoid occlusive footwear. Remove shoes and socks, when possible, to allow air circulation for feet and toes. 5. Apply dusting or drying powders as necessary. Using antifungal powders may prevent recurrence of infection. 6. Completion of therapy is important. 7. Avoid spreading the infection to others. Good hand-washing, thorough cleaning of bathrooms and avoidance of sharing bath towels and wash clothes may inhibit transmission. FOLLOW-UP Recheck in two weeks if not improved. REFERRAL 1. No improvement after two weeks of treatment. Child Health 10.185 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 2. Severe infection, or secondary bacterial infection. 3. Extension of the disease to the nails. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. Lawrence M. Tierney, et al., Current Medical Diagnosis and Treatment, 42nd ed., McGraw-Hill, 2003. (Current) Constance R. Uphold and Mary V. Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Gainesville, FL, 2003. (Current) Jane A. Fox, Primary Health Care of Infants, Children and Adolescents, 2nd ed., Mosby-Year Book, 2002. (Current) Thomas B. Fitzpatrick, et al., Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases, 4th ed., McGraw-Hill, New York, NY, 2001. (Current) American Academy of Pediatrics, Red Book: Report of the Committee on Infectious Diseases, 27th ed., Elk Grove Village, IL, 2006. Carol K. Takemoto et al., Pediatric Dosage Handbook, 2002-2003, 9th ed., Lexi-Comp, Inc., 2002. (Current) American Society of Health-Systems Pharmacists, American Hospital Formulary Service, Bethesda, MD, 2007, pp. 3465-3468, 3472-3475, 3494. Facts and Comparisons, Facts and Comparisons 4.0 Online, Wolters Kluwer Health, Inc., 2007 <http://online.factsandcomparisons.com>. Child Health 10.186 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR UPPER RESPIRATORY INFECTION (URI) (COMMON COLD) DEFINITION An acute infection of the upper respiratory tract involving the nose, pharynx, sometimes the paranasal sinuses and, perhaps, the middle ears. It lasts several days. Since the activity of the viruses in the upper respiratory tract can impair local defense mechanisms, invasion by bacteria may occur and cause infections of the ears and sinuses. ETIOLOGY Numerous viruses. In the U.S., peak incidences in children occur in early fall (when schools open), midwinter and early spring. Colds occur most commonly during the second and third years of life, and the average child has from three to eight infections per year. Malnutrition seems to increase susceptibility to colds. SUBJECTIVE 1. General malaise. 2. Nasal stuffiness, nasal discharge, sneezing, cough. 3. Mild sore throat. 4. Watery eyes. 5. Decreased appetite, particularly in infants. 1. Low-grade fever (<101F or <38.5C) occurs more commonly in children under 3 years old and lasts from a few hours to a few days. Older children usually have no fever; if they have a fever, evaluate for other causes, such as strep throat, otitis media, or pneumonia. 2. Erythematous, edematous nasal mucosa, with clear, thick nasal discharge initially. The discharge may become mucoid or purulent as the illness resolves. 3. Mildly erythematous pharynx. 4. Mild conjunctivitis. 5. Erythematous tympanic membranes in infants. (Rule out otitis media.) OBJECTIVE ASSESSMENT Common cold/upper respiratory infection (URI) Child Health 10.187 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 PLAN THERAPEUTIC PHARMACOLOGIC 1. Acetaminophen or Ibuprofen orally - Pediatric (See dosage chart with Nurse Protocol for Fever) if fever is associated with discomfort or decreased fluid intake. Do not use aspirin. 2. Treatment of cough is discouraged because cough is a protective mechanism that helps clear the lung of infectious particles. NOTE: The American College of Chest Physicians (ACCP) issued a recent advisory against antihistamines and decongestants for children with cough and/or congestion. They do not work and have side effects. NOTE: Past nurse protocol versions were cautious regarding their use but allowed support of their use if the parent claimed that they worked in the past. Edits were made to conform to the ACCP statement. NON-PHARMACOLOGIC 1. Increase oral fluid intake. 2. Infants: Use saline nose drops - one to two drops in each nostril, followed by gentle (caution: may aggravate nasal congestion if nasal mucosa is injured) aspiration of nasal secretions with rubber suction bulb, particularly before feeding. 3. Cool mist vaporizer, to loosen dried mucous and help reinstate normal ciliary movement that causes removal of the mucous. (Clean vaporizer daily with a solution of 1/2 cup Clorox to five cups water, to prevent fungal growth. Thoroughly rinse before use.) 4. Avoid environmental respiratory irritants (e.g., cigarette smoke in the home). 5. Elevate head of bed slightly. Child Health 10.188 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 CLIENT EDUCATION/COUNSELING 1. Rest and increased fluid intake. 2. Increase humidity of air at home. Instruct on use and cleaning of vaporizer. 3. Return to clinic if chest pain, dyspnea, signs of dehydration, wheezing, moist frequent cough, persistent abdominal pain or vomiting, persistent lethargy, agitation, behavioral changes, or confusion occur. 4. Good hand washing technique and proper disposal of tissues. FOLLOW-UP 1. No follow-up needed if symptoms resolve within one week. 2. Reevaluate if symptoms persist beyond 7-10 days OR if there is deterioration with return of fever after apparent improvement after 4-6 days of illness (suspect pneumonia). REFERRAL 1. Any infant or child with suspected secondary infection (e.g., pneumonia, sinusitis) or URI symptoms persisting longer than 2 weeks. 2. Persistent lethargy or irritability for >2 hours despite adequate treatment of fever. REFERENCES 1. 2. 3. Barton D. Schmitt, Instructions for Pediatric Patients, 2nd ed., W.B. Saunders, 1999. (Current) Richard E. Behrman et al., Nelson Textbook of Pediatrics, 17th ed., W.B. Saunders, Philadelphia, PA, 2004. (Current) Donald Bolser, “Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines,” Chest 2006, Volume 129, pp. 238S-249S. Child Health 10.189 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 NURSE PROTOCOL FOR VOMITING DEFINITION Vomiting is a prominent feature of many disorders of infancy and childhood and is often the only presenting symptom of many diseases. Vomiting is the forceful expulsion of gastric contents. It may be projectile or non-projectile. Projectile vomiting may indicate serious organicity such as pyloric stenosis or increased intracranial pressure. Vomiting occurs when violent descent of the diaphragm and constriction of the abdominal muscles actively force gastric contents back up the esophagus. ETIOLOGY Large number of possible causes including: viral, bacterial, hormonal (diabetes), bowel obstruction, appendicitis, increased intracranial pressure and many other pathologies. The etiology varies according to age group. SUBJECTIVE History should include: onset, frequency, presence of bile, duration, diet recall, family or close contacts with same symptoms, associated factors (e.g., fever, diarrhea), current medication/drug use, LMP and method of contraception (if applicable) and measures tried for relief of symptoms. Presence of diarrhea is reassuring. Vomiting plus diarrhea is almost always due to a viral infection. Vomiting without diarrhea should prompt a careful evaluation to rule out more serious causes of vomiting. OBJECTIVE 1. Check skin turgor for signs of dehydration. 2. Abdominal exam to check bowel sounds. 3. Palpate for masses and tenderness and pain with movement. 4. Determine that neck has full range of motion, with no stiffness. 5. Evaluate appearance and alertness. ASSESSMENT Vomiting, of unknown origin PLAN DIAGNOSTIC STUDIES 1. Check vital signs. 2. UCG (pregnancy test) if history suggests need. 2. Stool cultures if history of bloody or very-mucous stools. Child Health 10.190 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 3. If fever, refer to Nurse Protocol for Fever. THERAPEUTIC NON-PHARMACOLOGIC 1. Diet. See Pediatric Diets for Gastroenteritis (p. 10.91). 2. For infants and children, give only oral electrolyte solutions such as Pedialyte or Enfalyte until vomiting has ceased. Give liquids in small amounts, frequently increasing amounts as tolerated. In older children, may give sips of water, tea, flat cola or ginger ale, or ½ strength sports drinks, and increase amounts as tolerated. 3. See "Amount of formula typically taken on a self-demand schedule” (p. 10.89) and “Recommended Daily Intake of Water, Calories, and Protein for Full-Term Infants and Children” tables in the Gastroenteritis Nurse Protocol (p. 10.90). 4. Once vomiting has ceased, may advance diet to bland foods such as cooked cereal (grits, rice, oatmeal), applesauce, crackers, bananas and plain mashed potatoes may be given. Avoid spicy, greasy foods. CLIENT EDUCATION/COUNSELING 1. Diet instructions, as above. 2. Monitor the frequency of vomiting. (Greater than 8 times in less than 8 hours suggests increased risk.) 3. Monitor temperature. 4. Monitor urinary output. 5. Inform about increased symptoms of illness and what to do about them. Client should return promptly if there is persistent irritability, lethargy or signs of dehydration. 6. Stress hygiene and proper hand washing technique to prevent spread of infectious process. Child Health 10.191 Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008 REFERRAL 1. If vomiting is frequent (> 8x in 8 hrs as a rough guide). 2. If vomiting persists over 12 hours. 3. Infants less than 6 months of age. 4. Presence of blood or bile in vomitus. 5. Abdominal pain or tenderness that may suggest possibility of appendicitis or other focus. 6. Have worrisome associated symptoms: cough, dehydration, high fever, or constipation, GYN symptoms/signs, decreased ROM of neck, abnormal vital signs for age. 7. Lethargy, changes in mental status, headache. 8. History of abdominal surgery. REFERENCES 1. 2. 4. 5. Axalla J. Hoole et al., Patient Care Guidelines for Nurse Practitioners, 5th ed., Lippincott Williams & Wilkins, 1999. (Current) Georgia Dietetic Association, Diet Manual & Nutrition Practice Guidelines, 2004. (Current) M. William Schwartz, The 5-Minute Pediatric Consult, 3rd ed., Lippincott Williams & Wilkins, Baltimore, MD, 2003. (Current) G.R. Fleisher and S. Ludwig, Synopsis of Pediatric Emergency Medicine, Lippincott Williams and Wilkins, Baltimore, Md, 2002, pp. 258-264. Child Health 10.192