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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
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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
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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.
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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.
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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.
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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.)
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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
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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
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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
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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.
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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.)
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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)
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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.
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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.
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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.
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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.
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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.
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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.
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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.)
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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.
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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
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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.
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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)
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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.
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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
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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
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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.
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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.)
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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.
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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).
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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.
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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>.
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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
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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.)
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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.
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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.
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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.
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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)
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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).
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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)
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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.
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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.
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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
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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)
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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
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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.
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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)
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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.
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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
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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.
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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).
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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.
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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.
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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.
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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.
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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)
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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)
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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.
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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>.
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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
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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.
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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>.
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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 (<101F or <38.5C) 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)
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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.
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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.
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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.
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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.
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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.
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