Nursing Clinical setting

2

Advanced Nursing Clinical Research

Roseola is a viral disease that is commonly affecting younger children of ages between 6 months to 2 years old. The other names used about this condition include sixth disease, roseola infantum, and exanthem subitem. It is a mild infection that is caused by two strains of herpes viruses that usually affect children by the age of two years even though it occasionally affects adult patients. The disease is marked by symptoms such as high fever which is then followed by distinctive rashes after the breaks of the fever (Mullins & Krishnamurthy, 2020).

Concerning its pathophysiology for example in the primary infection, the virus replicates in the leukocytes and the salivary glands thus leading to the presence of the HHV-6 in the saliva. Exposure to the human herpesviruses (HHV) type 6 leads to the development of this condition among children. This condition is also caused by other types of herpes viruses called HHV 7. Just like any other virus, this disease is spread through smaller droplets of fluid especially when someone coughs, talks, or sneezes. The incubation period for roseola is two weeks and this implies that children with this condition that have not yet developed symptoms can easily spread it to other children (Mullins & Krishnamurthy, 2020). The outbreak of this condition can take place at any time of the year.

Early invasion of the central nervous system (CNS) takes place that leading to seizures and other complications of the CNS. There is evidence showing that a high level of serum of the matric metalloproteinase 9 and the tissue inhibitor of the metalloproteinase 1 in infants who have been infected by the HHV-6 results in a condition known as the blood-brain barrier dysfunction thus causing a febrile seizure on the patient (Yoshizato & Koga, 2020).

After an acute primary infection, HHV-6 remains to be latent in the lymphocytes and monocytes and is present in lower levels in several tissues. Peripheral blood mononuclear cell cultures develop into enlarged balloon-like cells. There are two variants of HHV-6 for example A and B with the latter leading to roseola.

Various symptoms guide the steps taken in the diagnosis of the roseola. This condition typically starts with sudden and high fever which is often 103 F. Other manifestations of this condition in children include the running nose, sore throat, and coughing along with or preceding the fever. It is also possible for these children to develop some swollen lymph nodes in their neck and this is also accompanied by fever which lasts for three to five days (Mullins & Krishnamurthy, 2020).

The skin rashes in children appear pink and are always flat and raised. The symptom of skin rashes usually begins on the abdomen and later spreads to other body organs such as the faces, arms, and legs. Presentation of symptoms like this is an indication that the virus is at the end of its course. Other key symptoms that can be noted are irritability, swelling of the eyelid, paining of the ear, a reduction in appetite, mild diarrhea, and convulsion as a result of the high fever (Ogata, et al., 2021).

Concerning the risk factors, older infants are at a higher risk of acquiring this disease since they have not yet developed their antibodies against the virus. While these children are in the uterus, they able to receive the antibodies from their mothers that are helping in protecting them against contracting infections like roseola (Mullins & Krishnamurthy, 2020). Nevertheless, this immunity is reduced with time and at the age of 6 to 15 months, they are highly exposed to this condition.

One of the major complications of roseola is seizures among children that are caused by an increase in body temperature. In case this happens, they are likely to lose their consciousness and jerk their arms, legs, or head for several seconds or minutes. They are also likely to temporarily lose their bladder or the control of their bowel. Therefore, parents are always advised to seek emergency care services in case children develop a seizure. This discussion is therefore focused on providing an evidence-based research paper on the details of the case study (Mullins & Krishnamurthy, 2020). The discussion is also based on the provision of thorough details on subjective and objective data of the patient presented in the case study; formulating the differential diagnosis; developing both non-pharmacological and pharmacological care plan; development of patient education; and follow-up plan.

The case scenario

Name: J.R Date of the visit: 6th June 2021 Time 1000hrs

Age 2-year-old Sex: F

Subjective

Chief Complaint (C/C): The mother of the patient reports her 2-year-old daughter's condition with the complaint of rashes that are present in the abdomen and are spreading to other regions of the body such as the hands and legs. The mother also reported a high-grade fever of 103.3 F that began 3 days ago that later resolved itself 24 hours ago.

History of the patient illness (HPI): a 2-year-old female patient is brought to the clinic with the complaint of rashes on the abdomen and is currently spreading to other parts of the body such as hands and legs as per the response provided by the mother. The patient had a high-grade fever of 103.3F that began 3 days before but later cleared and resolved on its own 24 hours ago. The fever is gone but is having rashes that started immediately after the fever had subsided.

The results from the examination of the patient reveal slight light pink rashes on the trunk and abdomen and pinkish conjunctiva. There is also a running nose and non-productive coughing that has been there for the past three days. The mother also reported the presence of scratch or itchy rashes, the diet is normal, and eats appropriately. The patient can move her bowels and urinate normally as well.

Medication: there is no reported medication that has been used for the patient.

Past Medication History: no report on medication history

Allergies: No record of any known drug allergic reaction of the patient

Intolerance to medication: no reported cases of medication intolerance from the mother

Chronic Illness or the Major traumas: based on the information provided by the mother the patient has never had any history of long-term care or hospitalization. She reports no history of trauma or any child-related abuse since she was born.

Family History: according to the report provided by the mother, the patient is the last born among the four children. She is the only daughter and her other siblings are healthy. The mother is a 45-year-old teacher while the father is a 55-year-old working as an accountant. The father is on medication for type 2 diabetes after being diagnosed with the disease at the age of 40 years older.

Social History: This is a 2-year-old child who enjoys playing with other kids in the company of her parents or her siblings. She enjoys swinging and riding the bicycle under the supervision of the patients. During the weekends, her father takes her together with other siblings to the swimming pools where they spend almost four hours on Sundays. She likes taking soft drinks and has been prevented from buying any food bought from an unknown source.

Assessment

Laboratory Test Procedures

For the correct diagnosis for this condition, one of the laboratory tests to be ordered is the complete blood work. This is done in response to the early acute febrile presentation especially when the child presents with the symptoms such as febrile seizures. Complete blood work helps in the determination of creatinine, chloride, glucose, and ALT. the other laboratory test to be ordered is the erythema infectiosum is used to rule out other conditions like the erythema infectiosum. This a benign condition that is characterized by a classic slapped-cheek appearance and the lacy exanthem. The disease presents similar symptoms just like the roseola, for example, the presence of rashes that appears after several days and might spread. It is also characterized by sore throat and slight fever (Garcia, et al., 2017). Therefore, this test is important to ensure that the prescribed medication will be aimed at treating roseola and relieving the patient from the symptoms once it is confirmed that erythema infectiosum is absent.

Another test to be ordered is aimed at ruling out the possibility of the measle disease. This involves the use of the swab taken from a sample of the saliva or blood sample that measured using the measle-specific immunoglobulin M (IgM). The urine samples can also be used to yield the virus and the IgM. Measle is a viral infection that is spread through the air by the respiratory droplets that are produced from coughing and sneezing. The key symptoms that are common for both measles and roseola are coughing, running nose, and skin rashes (Ma, et al., 2019). Therefore, the measle rash test is important in ruling out the possibility of the patient having it so that the focus can be put on the treatment of the roseola.

Another test is the test for rubella rash since it just presents like any other virus rashes. The confirmation of this disease is done through laboratory test procedures by performing the blood culture or the blood tests that help in the detection of various types of rubella antibodies in the patient blood. The spreading of this disease occurs through direct contact with the saliva or mucus of the infected person. The spread also occurs through the air by the respiratory droplets that are generated through coughing and sneezing. The symptom that are commonly shared by both roseola and rubella is fever which is mild in rubella (Ogata, et al., 2021). Therefore, it is important to perform the rash test for rubella so that effective treatment or medication prescribed for the patient can be targeted at treating roseola.

Another key laboratory test proposed in this case is the test for Human parvovirus infection. This test is done to help in ruling out this condition so that the focus is put on the treatment of the roseola. The test for test for Human parvovirus infection involves the withdrawal of the blood from the vein in the arm of the patient for the parvovirus B19 antibody test. This is important in the detection of this virus. The sample that can be used for this test can be blood or rarely the bone marrow in some patients. The fetal cord blood or the amniotic fluid is collected to help in testing for the fetal parvovirus B19 infection (Wang, et al., 2020). The reason for the performance of tests is because the symptoms of the roseola tend to be similar to those presented by the Human parvovirus infection. The common symptoms for the two conditions include rashes which tend to be mild for the patient with the Parvovirus B19 disease.

Diagnosis

Primary Diagnosis

Roseola (ICD-10 code 058.10) is the primary diagnosis for this patient based on the history of her condition and the symptoms presented. This is a common viral infection amongst younger children of ages between 6 months to 2 years older. Manifestation of the disease is in the form of rashes that appears smaller, high fever, and pinkish spots. The condition is marked by several days of high fever which is then followed by the distinctive rashes just after the break of the fever. Based on the report provided by the mother of the patient in this case scenario, the patient had rashes on her abdomen and later spread to the hand and legs. According to the mother, the patient had an increased high-grade fever of 103.3 F that began 3 days before and was cleared or resolved by itself 24 hours ago. This was followed by rashes that began after the fever had subsided (Xavier et al., 2019). On the physical examination at the facility, it is noted that the child had started developing pinkish conjunctiva and slight light pink rashes on the trunk and abdomen This confirms that the patient is having this condition.

Differential Diagnosis

Erythema infectiosum (B08.3): this is a benign childhood condition whose key features are classic slapped-cheek appearance and lacy exanthem. This disease is caused by the infection with human parvovirus (PV) B19. This condition leads to a distinctive face rash, sore throat, slight fever, upset stomach, headache, fatigue, and itching. Even though the patient in the case scenario presented symptoms such as rashes, the condition is ruled out since the patient never had a slight fever but a high-grade fever. It is also ruled out since the mother did not report any stomach upset and the child was eating normally and appropriately. The patient also never presented symptoms such as headache and behaviors that might indicate that she had some itching effects from rashes (Kostolansky & Waymack, 2018). According to the report from the mother, the toddler never scratch or itchy rashes

Upper respiratory infection (J06. 9.): this is a contagious infection that is caused by various types of bacteria and viruses for example influenza, step, and rhinoviruses. The infection affects the nose, throat, and the airways. This disease usually resolves after 10 days and symptoms resolving after 14 days. The key symptoms of this disease include sore throat, sneezing, stuffy nose, and coughing. Based on the symptoms of the patient in the case scenario, there were symptoms of non-productive cough and running nose. However, the condition is ruled out since there is no evidence or presence of rashes that were dominant in the patient's condition. The condition is also ruled out since the results from the examination of the child never showed any sneezing symptoms and a sore throat (Xavier et al., 2019).

Measle Rash (B05. 9): this condition is characterized by rashes that begin from the ears and extend towards the face, body, and then the arms and legs. The rash may be or may not be itchy and they begin three to five days after the symptoms had started. Rashes of this condition start as flat red spots that appears on the face at the hairline and spreading downwards to the neck, trunk, arms, legs, and feet. The patient may also present with small raised bumps on top of the flat red spots. Based on the symptoms of rashes of the patient in the case scenario, the condition is ruled out since rashes were not in the face but were dominant in the stomach and began to spread towards the legs and the arms. The appearance of rashes was not of the red spots but was a slight light pink rash on the trunk and the abdomen. There was also pinkish conjunctiva upon the inspection of the patient. Rashes of the patient in the case scenario were also not in the form of the raised bumps on top of the flat red spots (Hyser & Tjiattas-Saleski, 2017). The mother denied any scratching or itchy rashes by the patient.

Rubella rash (B06): Rubella is a contagious viral infection that is commonly recognized with distinctive red rashes. The condition results in a fine, pink rash that is common on the face and the trunk and then extending into the arms and the legs. Other key symptoms apart from the distinctive red rashes are mild fever and headache. The patient might also report coughing and sneezing as the symptoms that affect their normal health. Based on the symptom presented by the patient in the case study scenario, the patient presented with rashes that were common in the abdomen and spread to other parts of the body like the hands and the legs. There were also slight light pink rashes that were noted on the trunk and the abdomen of the patient. the key distinctive feature of rubella disease is the red rashes, therefore, the possibility of this child having this condition is ruled out (King & Al Khalili, 2020). The examination of the patient also never revealed any sneezing, therefore, it is unlikely possibility that the patient is having this condition.

Care plan

Nursing Intervention

One of the interventions is isolation to help in reducing the transmission within family members or the community. Skin-care is also necessary by ensuring that the patient's nail is kept shorter. Long pants and long sleeves are encouraged to prevent scratching and keeping the skin moist using the lotions that are recommended by the healthcare. The mother is informed to avoid direct sunlight and heat. ye care is also encouraged to help in the treatment of conjunctivitis using warm saline when removing eye secretions and encouraging the child not to rub eyes. Hydration is also promoted by encouraging the use of oral hydration. Temperature control is also another nurse intervention. The antipyretics are administered to the patient for a temperature that is greater than 100.4 F unless directed otherwise by the healthcare provider. The parents are advised to administer aspirin to prevent any complications associated with the condition.

Patient Education

The mother is informed to ensure that child's skin remains clean, dry, and intact. She is also advised to ensure that the patient's mucous membrane remains moist since discomfort will not be tolerated by the patient. She is informed about the importance of isolation in preventing the further spread of the condition. The mother is informed about the importance of ensuring that skin care is observed. This is important in the prevention of the pruritus (Ogata, et al., 2021). Therefore, she must ensure that the nails of the child are kept shorter and makes sure that her child is always on long pants and sleeves to prevent the possibility of scratching the skin. The mother is informed about the importance of hydration through the use of rehydration solutions. She is encouraged to adhere to the prescribed medication especially those meant to control the body temperature. Therefore, she must ensure that the body temperature of the patient is observed to prevent the complications such as convulsion.

Treatment

Pharmacological: There is no specific medication for roseola even though the physicians usually prescribe antiviral medication such ganciclovir to help in the treatment of the infection in individuals with the weakened immunity. Antipyretic can be prescribed to help in the management of the body temperature of the patient in this case scenario. Analgesic are prescribed to help in relieving pain, reduction of the potential inflammation, and reduction of fever. Acetaminophen in this case is stronger enough to assists with the reduction of discomfort caused by this condition (King & Al Khalili, 2020).

Non-pharmacological: this can involve the use of fluid replacement due to sweating, bleeding, vomiting or diarrhea, and dehydration. Fluid replacement is achieved by making the child drink a lot of fluids for example water, lemon-lime soda, electrolyte rehydration solutions such as Pedialyte, and the sports drinks like the Powerade. It is also important to ensure that the child has adequate bed rest by reducing playtime after injuries (Xavier et al., 2019). This is important in the promotion of the healing process to help in the full recovery of the patient.

Referral and the Follow-up

Usually, this condition disappears by itself, therefore, the patient is expected to report an improvement after 7 days. However, some situations that might force to take an urgent solution when the temperature of the patient is not dropping after the administration of analgesic or antipyretic. The patient can be referred for special examination where a further diagnosis can be made. The referral process is important in the prevention of preventable complications (Mullins & Krishnamurthy, 2020). The referral can also be made for a long-term and uncontrollable convulsion of the patient as a result of fever.

References

Garcia, R., Pereira, R., Azevedo, K. M., Castro, T. X., Mello, F., Setubal, S., & Oliveira, S. A. (2017). Molecular diversity of human parvovirus B19 during two outbreaks of erythema infectiosum in Brazil. Brazilian Journal of Infectious Diseases, 1, 102-106. https://doi.org/10.1016/j.bjid.2016.11.002 Hyser, E., & Tjiattas-Saleski, L. (2017). Febrile Exanthem. Osteopathic Family Physician, 9(4). King, O., & Al Khalili, Y. (2020). Herpes Virus Type 6. StatPearls [Internet]. Kostolansky, S., & Waymack, J. R. (2018). Erythema Infectiosum (Fifth Disease). Ma , R., Suo, L., Li, L., Zhangzhu, J., Chen, M., & Pang, X. (2019). Evaluation of the adequacy of measles laboratory diagnostic tests in the era of accelerating measles elimination in Beijing, China. Vaccine, 37(29), 3804-3809. https://doi.org/10.1016/j.vaccine.2019.05.058 Mullins, T. B., & Krishnamurthy, K. (2020). Roseola Infantum. StatPearls (Internet). Ogata, T., Murroka, M., Akashi, M., Ishitsuka, A., Miyazaki, A., Oswa, S., . . . Keiko, T.-T. (2021). The period from prodromal fever onset to rash onset in laboratory-confirmed rubella cases: a cross-sectional study. BMC Infectious Diseases, 21(1), 1-7. https://doi.org/10.1186/s12879-021-06158-9 Wang, Y., Hedman, L., Niurmi, V., Ziemele, I., Perdomo, M. F., Soderlund-Venermo, M., & Hedman, K. (2020). Microsphere-Based IgM and IgG Avidity Assays for Human Parvovirus B19, Human Cytomegalovirus, and Toxoplasma gondii. Msphere, 5(2), e00905-19. https://doi.org/10.1128/mSphere.00905-19 Xavier, A. R., Rodrigues, T., Santos, L. S., Larceda, G. S., & Kanaan, S. G. (2019). Clinical, laboratorial diagnosis and prophylaxis of measles in Brazil. Jornal Brasileiro de Patologia e Medicina Laboratorial, 55(4), 390-401. https://doi.org/10.5935/1676-2444.20190035 Yoshizato, R., & Koga, H. (2020). Comparison of initial and final diagnoses in children with acute febrile illness: A retrospective, descriptive study: Initial and final diagnoses in children with acute fever. Journal of Infection and Chemotherapy, 26(3), 251-256. https://doi.org/10.1016/j.jiac.2019.09.015