FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

MODULE #4 – ALTERATIONS WITH INFECTIOUS, INFLAMMATORY

AND IMMUNOLOGIC RESPONSE

INTRODUCTION

STIs have a profound impact on sexual and reproductive health worldwide. More than 1
million sexually transmitted infections occur every day. Each year, an estimated 376 million
infections occur with one of four curable STIs: chlamydia, gonorrhoea, syphilis and
trichomoniasis. More than 500 million people are living with genital herpes infection.
Approximately 300 million women have HPV infection and numbers among men are likely as
high. Studies have shown that the spread of HIV and other STI are closely related, STI are
identified as a co-factor for the causation of HIV infection and promiscuous behavior puts
people at risk for any sexually transmitted infections as well as HIV infection (86%). A person
with an STI has a much higher risk of acquiring HIV from an infected partner. A person infected
with both HIV and another STI has a much higher risk of transmitting HIV to an uninfected
Partner. Thus STI/RTI impose an enormous burden of morbidity and mortality in developing
countries, both directly through their impact on reproductive and child health, and indirectly
through their role in facilitating the sexual transmission of HIV infection. STIs can have serious
consequences beyond the immediate impact of the infection itself.

Bacterial meningitis is usually more severe and may lead to long-term complications.
Some children may have long-term problems with seizures, brain damage, hearing loss, and
disability. Bacterial meningitis can also cause death.

Most febrile seizures produce no lasting effects. Simple febrile seizures don't cause
brain damage, intellectual disability or learning disabilities, and they don't mean your child has
a more serious underlying disorder.

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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

LEARNING OUTCOMES:

After the successful completion of the module you should be able to:

LO1 Integrate concepts, theories and principles of sciences and humanities in the formulation
and application of appropriate nursing care of children with alterations in infectious response
to achieve quality maternal and child nursing care.

LO2 Apply maternal and child nursing concepts and principles in the prevention of alterations in
infectious response that place children at high risk holistically and comprehensively.

LO3 Assess children who is experiencing alterations in infectious response with the use of
specific methods and tools to address existing health needs.

LO4 Formulate nursing diagnoses to address needs / problems of children with alterations in
infectious response.

LO5 Implement safe and quality nursing interventions to meet the needs and promote optimal
outcomes for children with alterations in infectious response.

LO7 Evaluate with mothers and family the expected outcomes for the effectiveness and
achievement of care.

LO8 Institute appropriate corrective actions to prevent or minimize complications in children

with alterations in infectious response.

TOPIC OUTLINE:

I. Sexually Transmitted Infections

A. Trichomoniasis
B. Chlamydia trachomatis
C. Human papilloma virus
D. Herpes genitalis
E. Gonorrhea
F. Syphilis

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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

II. Meningitis
III. Febrile Seizure

CONTENT

I. SEXUALLY TRANSMITTED INFECTIONS

TRICHOMONIASIS

Trichomonas vaginalis is a single-cell protozoan that is spread by coitus and affects between 3%
and 13% of adult men and women in the United States. The incubation period is 4 to 20 days.

Assessment

With a trichomonal infection, females notice vaginal irritation and a frothy white or
grayish-green vaginal discharge. The frothiness of the discharge is an important typical finding.
The upper vagina is reddened and may have pinpoint petechiae. Extreme vulvar itching is
present. By contrast, males with the same infection rarely report any symptoms.
The infection is diagnosed by microscopic examination of a sample of the vaginal
discharge after it is combined with lactated Ringer’s or normal saline solution. Trichomonads
typically appear as rounded, mobile structures.

Therapeutic Management

Oral metronidazole (Flagyl) eradicates trichomonal infections. Treatment with Flagyl and
use of condoms by sexual partners help prevent recurrence of Trichomonas in both parties.
Because the drug interacts with alcohol to cause acute nausea and vomiting, advise women not
to drink alcoholic beverages during the course of treatment.
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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Pregnancy and Trichomoniasis

Trichomoniasis infections are associated with preterm labor, premature rupture of

membranes, and postcesarean infection (Hay & Czeizel, 2007). The drug of choice is single-dose
oral metronidazole. Metronidazole was once thought to be teratogenic but is now considered
to be safe in either early or late pregnancy (Karch, 2009).

CHLAMYDIA TRACHOMATIS

Chlamydia trachomatis infections have become the most common bacterial cause of STI
in the United States (Wendel & Zenilman, 2007). Symptoms include a heavy, grayish-white
discharge and vulvar itching. The incubation period is 1 to 5 weeks. Diagnosis is made by culture
of the organism. Therapy is oral doxycycline or tetracycline for 7 days or azithromycin in a single
dose. Because it has become so com- mon, most public health departments require that cases
now be reported. Long-term effects of chlamydial infections are PID, possibly leading to
subfertility. Because there is a strong association between gonorrhea and Chlamydia, if a
chlamydial infection is documented, women are usually tested for gonorrhea as well. Home
tests are available for both Chlamydia and gonorrhea.

Pregnancy and Chlamydia

Screening for Chlamydia via a vaginal culture is usually done during a woman’s first
prenatal visit. If a woman has multiple sexual partners, screening may be repeated again in the
third trimester. Doxycycline (Vibramycin), the therapy for nonpregnant women, is
contraindicated during pregnancy because of possible fetal long-bone deformities;
azithromycin (Zithromax) or amoxicillin (Amoxil) is used instead (Tanner & Alexander, 2007). A
woman’s partner also should be treated to prevent her from becoming reinfected. As with

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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

nonpregnant women, because there is a strong association between gonorrhea and Chlamydia,
if a chlamydial infection is documented, women are usually tested for gonorrhea as well.
Chlamydial infections must be treated during pregnancy because they are associated with
premature rupture of the membranes, preterm labor, and endometritis in the postpartum
period. An infant who is born while a chlamydial infection is present can suffer conjunctivitis or
pneumonia after birth.

HUMAN PAPILLOMAVIRUS (HPV)

The human papillomavirus (HPV) causes fibrous tissue overgrowth (sometime called
genital warts) on the external vulva, vagina, or cervix (condyloma acuminatum). At first, lesions
appear as discrete papillary structures; they then spread, enlarge, and coalesce to form large,
cauliflower-like lesions. The infection may be present in as many as 10% to 30% of women and
is most common in women who have multiple sexual partners (Howley & Lowy, 2007). Therapy
for such lesions is aimed at dissolving the lesions and also ending any secondary infection
present. Small growths may be removed by applying podophyllin (Podofin). Large lesions may
be removed by laser therapy, cryocautery, or knife excision. With cryocautery, edema at the
site is evident immediately; lesions become gangrenous, and sloughing occurs in 7 days. Healing
will be complete in 4 to 6 weeks with only slight depigmentation at the site. Sitz baths and a
lidocaine cream may be soothing during the healing period. Children (both male and female)
with HPV infections should be further investigated for sexual abuse (Reading & Rannan-Eliya,
2007). HPV infections are serious because they are associated with the development of cervical
cancer later in life (Soper, 2007). Women who have had one episode of infection should be
conscientious about having yearly Pap tests for the rest of their lives. The vaccine, Gardasil, is
recommended to be routinely administered to early teenage girls in three doses. A second dose
is 2 months after the first dose and the third dose is 6 months after the first dose. Immunizing
young teenage girls against HPV infection should reduce not only the incidence of HPV
infections in the future but the rate of cervical cancer as well (Deglin & Villarand, 2009).
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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Pregnancy and Human Papillomavirus Infection

HPV lesions tend to increase in size during pregnancy because of the high vascular flow
in the pelvic area. They may become secondarily ulcerated and infected; when this occurs, a
foul vulvar odor may develop. Podophyllum is contraindicated during pregnancy be- cause of
possible toxic effects on the fetus. Trichloroacetic acid (TCA) or bichloroacetic acid (BCA)
applied to the lesions weekly may be effective and can be used during pregnancy. Women who
do not find the lesions bothersome may choose to leave them in place during pregnancy and
have them removed during the postpartum period.
The presence of vulvar lesions appears to have no effect on the fetus during pregnancy,
but if they are present at the time of birth and so large that they obstruct the birth canal, a
cesarean birth may be scheduled.

HERPES GENITALIS (HERPES SIMLEX TYPE 2)

Genital herpes is caused by herpesvirus hominis type 2 (also called herpes simplex virus
type 2, or HSV-2). This is one of four similar herpesviruses: cytomegalovirus, Epstein-Barr,
varicella-zoster, and herpes types 1 and 2. Genital herpes occurs in epidemic proportions in the
United States, and its incidence appears to be growing yearly (Wendel & Zenilman, 2007).
Unlike most other STIs, although the virus can be contained, there is no known cure. The
disease involves a lifelong process, therefore, and, although it is not a precursor to cervical
cancer, women with cervical cancer tend to have more antibodies against herpes genitalis than
others or probably have been exposed to the virus more than others. The virus is spread by
skin-to-skin contact, entering through a break in the skin or mucous membrane. In the
newborn, the virus can be systemic or even fatal.

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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Assessment

Herpes is diagnosed by culture of the lesion secretion from its location on the vulva,
vagina, cervix, or penis or by isolation of HSV antibodies in serum. The incubation period is 3 to
14 days. On first contact, extensive primary lesions originate as a group of pinpoint vesicles on
an erythematous base. Within a few days, the vesicles ulcerate and become moist, painful,
draining, open lesions. An adolescent may have accompanying flulike symptoms with increased
temperature; vaginal lesions may cause a profuse discharge. Pain is intense on contact with
clothing or acidic urine.
After the primary stage that lasts approximately 1 week, lesions heal but the virus
lingers in a latent form, affecting the sensory nerve ganglia. The condition will flare up and
become an active infection during illness, just prior to menstruation, fever, overexposure to
sunlight, or stress. A secondary response usually produces only local lesions rather than
systemic symptoms.

Therapeutic Management

Acyclovir (Zovirax) is an example of an antiviral that controls the virus by interfering with
deoxyribonucleic acid reproduction and decreasing symptoms (Watkins, 2008). The drug is
available as a topical ointment. If applying this to a client, be certain to protect yourself with a
finger cot or glove so that you do not contract the virus or absorb the drug. Sitz baths three
times a day may be helpful to reduce discomfort. An emollient (A&D Ointment) can also reduce
discomfort, but its moisture tends to prolong the active period of the lesions. Topical
imiquimod (Aldara) or Foscarnet (Foscavir) may be prescribed for resistant lesions.
Condoms (male or female) help prevent the spread of her- pes among sexual partners.
Valacyclovir (Valtrex) may be prescribed as a preventive measure to help limit the disease
spread. Because of the possible association with cervical cancer, any female with genital herpes
should have yearly Pap tests for the rest of her life. People with herpes may have difficulty
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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

establishing sexual relationships for fear of infecting a partner. Because herpes is

communicated only by direct contact, infected people need to inform their partners when they
have any active lesions and avoid sexual contact or use a condom to decrease the danger of
spreading the virus.

Pregnancy and Herpes Simplex Virus Type 2 Infection

If a woman contracts a herpes type 2 infection during pregnancy, herpes can be

transmitted across the placenta to cause congenital infection in the newborn. If a woman has
primary or secondary active lesions in the vagina or on the vulva at the time of birth, herpes
infection can be transmitted to the newborn at birth. When infection in the newborn occurs,
congenital herpes, a severe systemic infection that is often fatal, can result. To help avoid
transmission, women with active lesions are scheduled for cesarean birth. If no lesions are
present, a vaginal birth is preferable (Tanner & Alexander, 2007).
Diagnosis of the disorder is made by the appearance of the lesions and on the results of
a Pap smear and an enzyme-linked immunosorbent assay (ELISA). The drug of choice for the
treatment of herpes infection is the same as for nonpregnant women (acyclovir [Zovirax] or
valacyclovir [Valtrex]) (Karch, 2009). Women can reduce the pain of the lesions by taking sitz
baths or applying warm, moist tea bags to the area.

GONORRHEA

Gonorrhea is transmitted by Neisseria gonorrhoeae, a gram-positive diplococcus that

thrives on columnar transitional epithelium of the mucous membrane. Symptoms begin after a
2- to 7-day incubation period. In males, they include urethritis (pain on urination and frequency
of urination) and a urethral discharge. Without treatment, the infection may spread to the
testes, scarring the tubules and causing permanent sterility. Untreated, the infection is easily
spread among sexual partners. It often occurs concurrently with chlamydial infection (Wendel
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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

& Zenilman, 2007). Although symptoms of gonorrhea in females are not as visible, there may be
a slight yellowish vaginal discharge. Bartholin’s glands may become inflamed and painful. If left
untreated, the infection may spread to pelvic organs, most notably the fallopian tubes (PID).
Tubal scarring can result in permanent sterility. In both males and females, untreated
gonorrhea can lead to arthritis or heart disease from systemic involvement.

Assessment

A urine culture for the gonococcal bacillus, in addition to vaginal and urethral cultures,
should be obtained from all children with vulvovaginitis or a urethral discharge. In males, a first
voiding may reveal gonococci if a midstream urine specimen is inconclusive.

Therapeutic Management

Although gonorrhea has traditionally been treated with amoxicillin and probenecid, the
incidence of penicillinase-producing strains has made this traditional therapy ineffective.
Therefore, oral cefixime (Suprax) or intramuscular ceftriaxone (Rocephin) plus oral doxycycline
(Vibramycin) for 7 days is the current recommended therapy. This treatment regimen is
effective for both gonorrhea and Chlamydia. Sexual partners should receive the same
treatment. Approximately 24 hours after treatment, gonorrhea is no longer infectious.
Approximately 7 days after treatment, a client should return for a follow-up culture to verify
that the disease has been completely eradicated (few adolescents take this precaution).
Adolescents are usually assessed for syphilis along with the gonorrheal culture, although the
dose of ceftriaxone and doxycycline is also effective treatment for syphilis. Most states require
that gonorrhea be reported to the health department; adolescents are asked to name sexual
contacts.

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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Pregnancy and Gonorrhea

Gonorrhea is associated with spontaneous miscarriage, preterm birth, and endometritis

in the postpartum period. Pregnant women cannot be administered doxycycline because it has
the potential to be terato- genic. Instead, they are prescribed amoxicillin or azithromycin. It is
important that gonorrhea be identified and treated during pregnancy because if the infection is
present at the time of birth, it can cause a severe eye infection that can lead to blindness in the
newborn (ophthalmia neonatorum).

SYPHILIS

Syphilis is a systemic disease caused by the spirochete Treponema pallidum. It is

transmitted by sexual contact with a person who has an active spirochete-containing lesion
(Tanner & Alexander, 2007). Like gonorrhea and Chlamydia, it must be reported to public health
departments. After an incubation period of 10 to 90 days, a typical lesion appears, usually on
the genitalia (penis or labia) or on the mouth, lips, or rectal area from oral–genital or genital–
anal contact. The lesion (termed a chancre) is a deep ulcer and is usually painless despite its
size. Swollen lymph nodes may be present but these are unlikely to be noticed by the affected
person. A lesion in the vagina may not be detected. Without treatment, a chancre lasts
approximately 6 weeks and then fades.
Approximately 2 to 4 weeks after the chancre disappears, a generalized, macular,
copper-colored rash appears. Unlike many other rashes, it affects the soles and the palms. A
serologic test for syphilis yields a positive result at this time. There may be secondary symptoms
of generalized illness, such as low-grade fever. With or without treatment, this stage of syphilis
also fades.
The next stage is a latency period that may last from only a few years to several
decades. The only indication of the dis- ease is the serologic test, which continues to yield a
positive result.
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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

The final stage of syphilis is a destructive neurologic disease that involves major body
organs such as the heart and the nervous system. Typical symptoms are blindness; paralysis;
severe, crippling neurologic deformities; mental confusion; slurred speech; and lack of
coordination. This third stage must be identified before the disease becomes fatal.

Assessment

Syphilis is diagnosed by recognition of the various symptoms of the three stages and by
serologic serum tests, usually the Venereal Disease Research Laboratory test (VDRL), the
automated reagin test (ART), the rapid plasma reagin test (RPR), or the fluorescent treponemal
antibody–absorption test (FTA-ABS).

Therapeutic Management

Benzathine penicillin G, given intramuscularly in two sites, is effective therapy. For the
adolescent who is sensitive to penicillin, either oral erythromycin or tetracycline can be given
for 10 to 15 days. Sexual partners are treated in the same way as the person with the active
infection. Therapy effectively arrests the disease at whatever stage it has reached. After
therapy, adolescents may experience a sudden episode of hypotension, fever, tachycardia, and
muscle aches. This is called a Jarisch-Herxheimer reaction and is caused by the sudden
destruction of spirochetes. The reaction lasts about 24 hours and then fades (Wendel &
Zenilman, 2007). Because syphilis can be treated so easily, one would think it would be easy to
eradicate. In reality, however, because the primary chancre is painless, many people are either
unaware of it or choose to ignore it, thereby transmitting the disease to unsuspecting partners.
Adolescents, in particular, need accurate information about syphilis to become aware of the
symptoms and safer sex practices. They should believe that they can report the disease to
health care personnel and can name sexual contacts without fear of being criticized (Leung-
Chen, 2008).
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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Pregnancy and Syphilis

Early in pregnancy (before week 18), the placenta appears to provide some protection
against syphilis. After this time, however, the spirochete crosses the placenta freely and may be
responsible for spontaneous miscarriage, preterm labor, stillbirth, or congenital anomalies in
the newborn. All pregnant women are screened for syphilis at a first prenatal visit with a VDRL,
ART, or FTA-ABS antibody reaction test. Those who have multiple sexual partners are tested
again at about week 36 of pregnancy. In some institutions, women are screened again at the
beginning of labor and newborns are screened for congenital syphilis by a cord blood sample.
One injection of benzathine penicillin G is the drug of choice for the treatment of syphilis during
pregnancy the same as for those who are not pregnant.
If a woman does contract syphilis during pregnancy and it is untreated, a congenital
form of the disease can occur in the newborn as the spirochete crosses the placenta readily in
the last four months of pregnancy. Severely infected infants will be stillborn; others, less
infected, are born with congenital anomalies. Moist lesions of the infant (the cord and nasal
secretions) are generally infectious.
Unlike adults, the infant does not develop a chancre but about a week after birth, will
develop a typical copper-colored rash, most prominent over the face, soles of feet, and palms
of hands. Bullous lesions on the palms and soles may also develop. The infant’s nose may show
a severe rhinitis (snuffles). Radiography of the long bones reveal changes of epiphyseal lines at
about 1 to 3 months of age. By 5 to 6 months, these bone changes may no longer be visible and
so may be missed.
When the child’s permanent teeth erupt at 5 or 6 years of age, they may be pegged or
notched (Hutchinson’s teeth). This is most noticeable in the upper central incisors. All teeth
tend to be of poor quality and decay easily. If the disease remains untreated, interstitial
keratitis, an inflammatory reaction of the cornea that can result in scarring and blindness, may
develop when the child is school age. As the disease progresses further, it may become tertiary
or lead to severe neurologic symptoms.
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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Infants born to a woman with a positive VDRL are given a course of penicillin at birth.
FTA-ABS is a sensitive, specific test for IgM antibodies against syphilis and may be helpful for
diagnosis in the newborn.

II. MENINGITIS

Meningitis is an infection of the cerebral meninges. It occurs most often in children

younger than 24 months of age. Although the disease can occur in any month, its peak
incidence appears to be in the winter. In the United States, it is caused most frequently by
Streptococcus pneumoniae or group B Streptococcus. In children younger than 2 months of
age, group B Streptococcus and Escherichia coli are common causes of meningitis. In children
with myelomeningocele who develop meningitis, Pseudomonas infection is common. Children
who have had a splenectomy are particularly susceptible to pneumococcal meningitis unless
they have received a pneumococcal vaccine. Haemophilus influenzae, once a major cause of
meningitis, is now rarely seen because of routine immunization against this organism (Murphy,
2008).
Pathologic organisms usually are spread to the meninges from upper respiratory tract
infections, by lymphatic drainage possibly through the mastoid or sinuses, or by direct
introduction through a lumbar puncture or skull fracture. Once organisms enter the meningeal
space, they multiply rapidly and spread throughout the CSF. Organisms invade brain tissue
through meningeal folds that extend down into the brain itself. The inflammatory response that
occurs may lead to a thick, fibrinous exudate that blocks CSF flow. Brain abscess or invasion of
the infection into cranial nerves can result in blindness, deafness, or facial paralysis. Pus that
accumulates in the narrow aqueduct of Sylvius can cause obstruction leading to hydrocephalus.
Brain tissue edema can put pressure on the pituitary gland, causing increased production of
antidiuretic hormone, resulting in the syndrome of inappropriate antidiuretic hormone

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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

secretion (SIADH). This causes increased edema because the body cannot excrete adequate
urine.

Assessment

The symptoms of meningitis occur either insidiously or suddenly. Children usually have
had 2 or 3 days of upper respiratory tract infection. They become increasingly irritable because
of headaches. They have sharp pain on bending their head forward. They may have seizures. In
some children, seizure or shock is the first noticeable sign of illness. As the disease progresses,
signs of meningeal irritability occur, as evidenced by positive Brudzinski’s and Kernig’s signs
(Fig. 49.10). Children’s backs may become arched and their necks hyperextended
(opisthotonos). Cranial nerve paralysis, most typically of the third and sixth nerves, may occur,
so that the child is not able to follow a light through full visual fields. If the fontanelles are open,
they are bulging and tense; if they are closed, papilledema may develop. If the meningitis is
caused by H. influenzae, the child may develop septic arthritis. If it is caused by N. meningitidis,
a papular or purple petechial skin rash may occur (Milonovich, 2007).
In the newborn, symptoms such as poor sucking, weak cry, or lethargy are often vague.
After this generalized beginning, sudden cardiovascular shock, seizures, nuchal rigidity, or
apnea may occur. Because the infant has open fontanelles, nuchal rigidity appears late and is
not as useful a sign for diagnosis as in the older child.
Meningitis is diagnosed by history and analysis of CSF obtained by lumbar puncture. A
child with a febrile seizure should be assumed to have meningitis until CSF findings prove
otherwise. CSF results indicative of meningitis include increased white blood cell and protein
levels and a lowered glucose level (because bacteria have fed on the glucose). In a healthy child,
the glucose level in the CSF is 60% of that of the serum glucose. Because meningitis often
spreads and causes septicemia, a blood culture also is done. A fulminating (overwhelming)
meningitis often leads to leukopenia. If the child has had close association with someone with
tuberculosis, a tuberculin skin test to rule out tuberculosis meningitis should be done. A CT
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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

scan, MRI, or ultrasound study may be ordered to examine for abscesses. Typically, ICP is
severely elevated.

Therapeutic Management

Antibiotic therapy as indicated by sensitivity studies is the primary treatment measure.

Usually antibiotics are given IV for rapid effect, but intrathecal injections (directly into the CSF)
may be necessary to reduce the infection, because the blood–brain barrier may prevent an
antibiotic from passing freely into the CSF. If the organism is identified as H. influenzae,
ampicillin usually is the drug of choice. In other instances, a third-generation cephalosporin,
such as cefotaxime (Claforan) or ceftriaxone (Rocephin), may be used for 8 to 10 days. In some
children, it takes a month before the CSF cell count returns to normal. A corticosteroid such as
dexamethasone or the osmotic diuretic, mannitol, may be administered to reduce ICP and help
prevent hearing loss.
In addition to standard precautions, children with meningitis are placed on respiratory
precautions for 24 hours after the start of antibiotic therapy to prevent transmission of the
infection. Antibiotics also may be prescribed prophylactically for the immediate family
members of the ill child or for others who have been in close contact with the child.
Meningitis is always a serious disorder, because it can run a rapid, fulminating, and
possibly fatal course. However, if symptoms are recognized early and treatment is effective, a
child will recover with no sequelae. Neurologic sequelae, such as learning problems, seizures,
hearing and cognitive challenges, and inability to concentrate urine from poor antidiuretic
hormone secretion, must be assessed after the infection, because these can be long-term
consequences.

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 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Group B Streptococcal Infection

A major cause of meningitis in newborns is group B streptococci. The organism is

contracted either in utero or from secretions in the birth canal. It can spread to other newborns
if good handwashing technique is not used. Group B streptococci colonization can result in
either early-onset or late-onset illness. With the early-onset form, symptoms of pneumonia
become apparent in the first few hours of life. The late-onset type leads to meningitis instead of
pneumonia.
At approximately 2 weeks of age, the infant gradually becomes lethargic and develops a
fever and upper respiratory tract symptoms. The fontanelles bulge from increased ICP.
Mortality from group B streptococcal infection is approximately 25%; surviving infants may
develop neurologic consequences such as hydrocephalus or seizures (Ogle & Anderson, 2008).
Treatment is with antibiotics, such as ampicillin and cephalosporins, that are effective against
group B streptococcal infections. It can be difficult for parents to understand how their infant
suddenly became so ill. They may need considerable support in caring for the infant if the infant
is left neurologically challenged.

III. FEBRILE SEIZURES

Seizures associated with high fever (102° to 104° F [38.9° to 40.0° C]) are the most
common type seen in preschool children (5 months to 5 years), although these can occur as
early as 3 months or as late as 7 years of age. Febrile seizures may occur after immunization
because of an accompanying fever. Seizures show an active tonic–clonic pattern, which lasts for
15 to 20 seconds. The EEG tracing usually is normal. There usually is a history of other family
members having had similar seizures.

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Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Febrile seizures usually occur due to a sudden spike of temperature. The seizure only
lasts 1 to 2 minutes or less. Such seizures must be taken seriously, however, and investigated
for a possible cause, because meningitis often manifests initially with high fever and a seizure
(Middleton, 2008).

Prevention of Febrile Seizures

Because these seizures arise with high fever, they are largely preventable. If
acetaminophen is given to keep a developing fever below 101° F (38.4° C), seizures rarely occur.
They happen most often when a child develops a fever at night, when a parent is not aware of
it, or when a parent is reluctant to give acetaminophen in large enough doses to be
therapeutic. Although this type of seizure can be prevented by phenobarbital, prophylactic use
during an upper respiratory tract infection is not recommended, because phenobarbital takes 2
or 3 days to reach therapeutic blood levels. By this time, the seizures would already have
occurred. In addition, phenobarbital is associated with sleepiness, which possibly reduces
cognitive function in children. If a second febrile seizure occurs, diazepam (Valium) may be
prescribed for the parents to administer the next time the child has a high fever (Moe, Benke, &
Bernard, 2008).

Instruct parents that every child who has a febrile seizure must be seen by a health care
provider to rule out meningitis. A good rule is to assume that the child in this situation has
meningitis until it is ruled out by a complete neurologic workup.

Therapeutic Management

Teach parents that, after a seizure subsides, to sponge the child with tepid water to
reduce the fever quickly. Advise them not to put the child in the bathtub, however, because it
would be easy for the child to slip under water should a second seizure occur. Applying alcohol
or cold water is also not advisable. Extreme cooling causes shock to an immature nervous
system; in addition, alcohol can be absorbed by the skin or the fumes can be inhaled in toxic

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Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

amounts, compounding the child’s problems. Parents should not attempt to give oral
medications such as acetaminophen, because the child will be in a drowsy, or postictal, state
after the seizure and might aspirate the medicine. If attempts to reduce the child’s temperature
by sponging are unsuccessful, advise parents to put cool wash-cloths on the child’s forehead,
axillary, and groin areas and transport the child, lightly clothed, to a health care facility for
immediate evaluation.

Additional treatment depends on the underlying cause of the fever. A lumbar puncture
will be performed to rule out meningitis. Antipyretic drugs to reduce the fever below seizure
levels will be administered. Appropriate antibiotic therapy will be started, depending on the
type of infection.

Many parents need to be reassured that febrile seizures do not lead to brain damage
and that the child is almost always completely well afterward.

LEARNING RESOURCES:

1. STD - https://www.youtube.com/watch?v=XcPCY83FIvk

LEARNING ACTIVITIES:

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NUR 1210 – PEDIA CONCEPT (Wilfredo D. Quijencio Jr., MD, RN, RM, MAN, LPT, MPH)
Prepared by MCN FEU Faculty Lecturers January 2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020 – 2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

REFERENCES:

Pillitteri A. Maternal and child health nursing. Care of the childbearing and childrearing family.
Eight edition. Philadelphia; Lippincott Williams & Wilkins: 2018.

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