BIOGRAPHICAL DATA

Name: Baby AC Birthdate: August 02, 2010 Address: Dona Faustina II Machaca Camp Cul, Quezon City Religion: Roman Catholic Nationality: Filipino Fathers Name: Mr. PC Mothers name: Mrs. EC Admission: May 07, 2011 (05:20 AM) Admitting Diagnosis: Infected Varicella Attending Physician: Dr. Rachelle A Grafil Sex: Female Age: 9 months old

HEALTH HISTORY

CURRENT HEALTH PROBLEMS

The condition of the patient started on May 03, 2011, when the mother noticed vesiculomaculo rash starting from the head going to lower extrimities with accompanying symptoms of fever and vomiting. They went to Barangay Health Center and prescribed with Paracetamol and Immunosin. There was no relief of the symptoms of the patient.

May 06, 2011, persistence of Bullous lesion prompted consult at East Avenue Medical Center then referred to San Lazaro Hospital hence admitted.

PAST HEALTH PROBLEMS

It was her 2nd hospitalization. Her 1st confinement was due to Sepsis Neonatorum 8 months ago. Her common illness includes cough, colds, and fever. Her mother usually gave her a Paracetamol to relieve her fever. She received 1 dose of BCG, 1 dose Hepa B, 3 doses of OPV, 3 doses of DPT except for measles. She had no known allergies to drugs, foods, and agents.

OBSTETRICAL HISTORY

During Mrs. ECs pregnancy, she always go for check- ups in their Barangay Health Center and was completed her Tetanus Toxoid Vaccine. Baby AC delivered in a Normal Spontaneous Delivery without any known complications. Baby AC is a breastfed baby until now but also eats soft foods such as crashed potato and cereals.

FAMILY RISK FACTORS

The family is residing at Bucaue, Bulacan. Mrs. EC verbalized that one of her cousin had chicken pox. Their common illnesses are cough, colds, headache and fever. They usually take OTC meds to relieve their illness such as Robitusin for cough and colds, Alaxan for headache and Paracetamol for Fever. There is no known diseases noted that runs in their family. There are no known allergies noted in their family.

MEDICATION

Paracetamol drops q4hours for fever Zinc Oxide to apply in diaper rash Cloxacillin 250mg/ 5mL QID

PERSON ASSESSMENT
PSYCHOSOCIAL Lives at Bucaue, Bulacan with her mother and 2 sisters, ages 5 years old and 3 years old. Her mother and her father separated 5 months ago due to failure to provide the needs of their family. Her grandmother was the one who provide their needs even her hospital bills. Her mother is a house wife. She is a Roman Catholic. She was baptized when she was 5 months old. Her mother usually brought her to Barangay Health Center for health consultation. Before hospitalization, she weighs 8.7kgsand now she weighs 7.4kgs. She is active and playful upon assessment. ELIMINATION She consumed two diapers per day if there is no stool present. She defecates once a day, sometimes the color is yellow and sometimes green in color. REST AND ACTIVITY She has 16 hours of sleep. Her sleeping time is usually around 7pm and usually wakes up around 11am. Sometimes she wakes up in the midnight due to needs to be breastfed. She usually take a naps around 1pm.

SAFE ENVIRONMENT

She has no known allergy in medications and foods. She has dry skin, presence of crust and macules. The mucous membrane is normal in color and there is no presence of dryness. Her present temperature is 37C. On admission her temperature is 39.4C. Medicated with paracetamol, oxacillin and zinc oxide. Medicated at home with paracetamol for her fever. Upon admission her WBC is 17.19 due presence of infection.

OXYGEN

There is no presence of murmur sound. No accessory muscles being used. Her respiratory rate is 29 cpm. Her cardiac rate is 11O bpm. No presence of edema. ( - ) homans sign. Upon admission her Hb: 10.48, Hct: 37.79, and RBC of 402. Blunch test done; capillary refill immediately back to its normal color.

NUTRITION

Still on breast feed, but sometimes her mother gives her soft foods e.g. crashed biscuits. She is also a bottlefed baby, uses bearbrand and consumed 1L of milk per day. She has good appetite. She weighs 7.4, weight loss of 1.3 kgs. over past 4 days. IV: D5 IMB 500cc @ 21 gtts/hour. She is on diet according to age as ordered.

DRUG STUDY

NAME OF DRUG/GENERIC DRUG CLASIFICATION OXACILLIN (PINICILLIN) BETA-LACTAMASE INHIBITOR DOSAGE: 90 mg/kg/day P.O Q 12 hours for 10 days

ACTION RATIONALE BACKTERICIDAL INHIBITS THE ENZYME IN CELL WALL SYNTHESIS

SIDE EFFECT

NURSING IMPLICATION

NAUSEA, VOMITING, DIARRHEA, RASH, STOMATITIS, HERPENSENSITIVITY RANGING FROM RASH, UNRTICARIA SUPER INFECTION SIGN/SYNTOMS, BLACK,FURRY TONGUE, THRUSH, AND VIGINAL DISCHARGE

MONITOR V/S MONITOR WBC MONITOR I&O CHECK FOR BLEEDING OF HIGH DOSE OF PENICILLIN. CULTURE & SENSITIVITY REPORTS RENAL FUNCTION TEST

PARACETAMOL (ACETAMINOPHEN) PARA-AMINOPHENNOL DERIVATIVE DOSAGE: 80 mg P.O Q 4 to 6 hours P.R.N

PRODUCE ANALGESIA BY BLOCKING PAIN IMPULSES BY INHIBITING SYNTHESIS OF PROSTAGLANDIN IN THE CNS

HEMATOLOGIC: HEMOLYTIC ANEMIA, LEUKOPENIA, NEUTROPENIA, PANCYTOPENIA HEPATIC: JAUNDICE METABOLIC: HYPOGLYCEMIA SKIN: RASH & URTICARIA

MONITOR V/S MONITOR I&O MONITOR WBC,RBC CHECK FOR GLUCOSE AND HEMOGLOBIN

CHICKEN POX

Chickenpox is a highly contagious illness caused by primary infection with varicella zoster virus (VZV). It usually starts with vesicular skin rash mainly on the body and head rather than at the periphery and becomes itchy, raw pockmarks, which mostly heal without scarring.

Chickenpox is an airborne disease spread easily through coughing or sneezing of ill individuals or through direct contact with secretions from the rash. A person with chickenpox is infectious from one to five days before the rash appears. The contagious period continues for 4 to 5 days after the appearance of the rash, or until all lesions have crusted over. Immunocompromised patients are probably contagious during the entire period new lesions keep appearing. Crusted lesions are not contagious. It takes from 10 to 21 days after contact with an infected person for someone to develop chickenpox.

The onset of

illness with chickenpox is often characterized by symptoms

including myalgia, nausea, fever, headache, sore throat, pain in both ears, complaints of pressure in head or swollen face, and malaise in adolescents and adults. In children, the first symptom is usually the development of a papular rash, followed by development of malaise, fever (a body temperature of 38 C (100 F), but may be as high as 42 C (108 F) in rare cases), and anorexia. Typically, the disease is more severe in adults. Chickenpox is rarely fatal, although it is generally more severe in adult males than in adult females or children. Non-immune pregnant women and those with a suppressed immune system are at highest risk of serious complications. Chickenpox is believed to be the cause of one third of stroke cases in children. The most common late complication of chickenpox is shingles, caused by reactivation of the varicella zoster virus decades after the initial episode of chickenpox.

DIAGNOSIS

The diagnosis of varicella is primarily clinical, with typical early "prodromal" symptoms, and then the characteristic rash. Confirmation of the diagnosis can be sought through either examination of the fluid within the vesicles of the rash, or by testing blood for evidence of an acute immunologic response.

Vesicular fluid can be examined with a Tsanck smear, or better with examination for direct fluorescent antibody. The fluid can also be "cultured", whereby attempts are made to grow the virus from a fluid sample. Blood tests can be used to identify a response to acute infection (IgM) or previous infection and subsequent immunity (IgG).

Prenatal diagnosis of fetal varicella infection can be performed using ultrasound, though a delay of 5 weeks following primary maternal infection is advised. A PCR (DNA) test of the mother's amniotic fluid can also be performed, though the risk of spontaneous abortion due to the amniocentesis procedure is higher than the risk of the baby developing foetal varicella syndrome.

EPIDEMIOLOGY

Primary varicella is an endemic disease. Cases of varicella are seen throughout the year but more commonly in winter and early spring. Varicella is one of the classic diseases of childhood, with the highest prevalence in the 410 year old age group. Like rubella, it is uncommon in preschool children. Varicella is highly communicable, with an infection rate of 90% in close contacts. Most people become infected before adulthood but 10% of young adults remain susceptible.

Historically, varicella has been a disease predominantly affecting young school-aged children. In adults the pock marks are darker and the scars more prominent than in children.

PATHOPHYSIOLOGY

Exposure to VZV in a healthy child initiates the production of host immunoglobulin

G (IgG),immunoglobulin M (IgM), and immunoglobulin A (IgA) antibodies; IgG antibodies persist for life and confer immunity. Cell-mediated immune responses are also important in limiting the scope and the duration of primary varicella infection. After primary infection, VZV is hypothesized to to spread local sensory

frommucosal and epidermal lesions

nerves. VZV then remains latent in the dorsal ganglion cells of the sensory nerves. Reactivation of VZV results in the clinically distinct syndrome of herpes

zoster (i.e., shingles), and sometimes Ramsay Hunt syndrome type II.

INFECTION IN PREGNANCY AND NEONATES

For pregnant women, antibodies produced as a result of immunization or previous infection is transferred via the placenta to the fetus. Women who are immune to chickenpox cannot become infected and do not need to be concerned about it for themselves or their infant during pregnancy.

Varicella infection in pregnant women could lead to viral transmission via the placenta and infection of the fetus. If infection occurs during the first 28 weeks of gestation, this can lead to fetal varicella syndrome (also known as congenital varicella syndrome). Effects on the fetus can range in severity from underdeveloped toes and fingers to severe anal and bladder malformation. Possible problems include:

Damage to brain: encephalitis, microcephaly, hydrocephaly, aplasia of brain Damage to the eye: optic stalk, optic cup, and

lens vesicles, microphthalmia, cataracts,chorioretinitis, optic atrophy

Other neurological disorder: damage to cervical and lumbosacral spinal cord, motor/sensory deficits, absent deep tendon reflexes, anisocoria/Horner's syndrome

Damage

to

body: hypoplasia of

upper/lower

extremities,

anal

and

bladder sphincter dysfunction

Skin disorders: (cicatricial) skin lesions, hypopigmentation

Infection late in gestation or immediately following birth is referred to as "neonatal varicella". Maternal infection is associated with premature delivery. The risk of the baby developing the disease is greatest following exposure to infection in the period 7 days prior to delivery and up to 7 days following the birth. The baby may also be exposed to the virus via infectious siblings or other contacts, but this is of less concern if the mother is immune. Newborns that develop symptoms are at a high risk of pneumonia and other serious complications of the disease.

SHINGLES After a chickenpox infection, the virus remains dormant in the body's nerve tissues. The immune system keeps the virus at bay, but later in life, usually as an adult, it can be reactivated and cause a different form of the viral infection called shingles.

PREVENTION

HYGIENE MEASURES The spread of chicken pox can be prevented by isolating affected individuals. Contagion is by exposure to respiratory droplets, or direct contact with lesions, within a period lasting from three days prior to the onset of the rash, to four days after the onset of the rash. The chicken pox virus (VZV) is susceptible to disinfectants, notably chlorine bleach (i.e., sodium hypochlorite). Also, like all enveloped viruses, VZV is sensitive to desiccation, heat and detergents. Therefore these viruses are relatively easy to kill.

VACCINE Main article: Varicella vaccine A varicella vaccine was first developed by Michiaki Takahashi in 1974 derived from the Oka strain. It has been available in the U.S. since 1995 to inoculate against the disease. Some countries require the varicella vaccination or an exemption before entering elementary school. Protection from one dose is not lifelong and a second dose is necessary five years after the initial immunization, which is currently part of the routine

immunization schedule in the US. The chickenpox vaccine is not part of the routine childhood vaccination schedule in the UK. In the UK, the vaccine is currently only offered to people who are particularly vulnerable to chickenpox.

TREATMENT Varicella treatment mainly consists of easing the symptoms as there is no actual cure of the condition. Some treatments are however available for relieving the symptoms while the immune system clears the virus from the body. As a protective measure, patients are usually required to stay at home while they are infectious to avoid spreading the disease to others. Also, sufferers are frequently asked to cut their nails short or to wear gloves to prevent scratching and to minimize the risk of secondary infections. The condition resolves by itself within a couple of weeks but meanwhile patients must pay attention to their personal hygiene. The rash caused by varicella zoster virus may however last for up to one month, although the infectious stage does not take longer than a week or two. Also, staying in a cold surrounding can help in easing the itching as heat and sweat makes it worse. Although there have been no formal clinical studies evaluating the effectiveness of topical application of calamine lotion, a topical barrier preparation containing zinc oxide and one of the most commonly used interventions, it has an excellent safety profile. It is important to maintain good hygiene and daily cleaning of skin with warm water to avoid secondary bacterial infection. Scratching may also increase the risk of secondary infection. To relieve the symptoms of chicken pox, people commonly use anti-itching creams and lotions. These lotions are not to be used on the face or close to the eyes. An oatmeal bath also might help ease discomfort.

CHILDREN If oral acyclovir is started within 24 hours of rash onset it decreases symptoms by one day but has no effect on complication rates. Use of acyclovir therefore is not currently recommended for immunocompetent individuals (i.e., otherwise healthy persons without known immunodeficiency or on immunosuppressive medication). Children younger than 12 years old and older than one month are not meant to receive antiviral medication if they are not suffering from another medical condition which would put them at risk of developing complications.

Treatment of chicken pox in children is aimed at symptoms whilst the immune system deals with the virus. With children younger than 12 years cutting nails and keeping them clean is an important part of treatment as they are more likely to deep scratch their blisters. Aspirin is highly contraindicated in children younger than 16 years as it has been related with a potentially fatal condition known as Reye's syndrome.

ADULTS Infection in otherwise healthy adults tends to be more severe and active; treatment with antiviral drugs (e.g. acyclovir) is generally advised, as long as it is started within 2448 hours from rash onset. Remedies to ease the symptoms of chicken pox in adults are basically the same as those used on children. Moreover, adults are often prescribed antiviral medication as it is effective in reducing the severity of the condition and the likelihood of developing complications. Antiviral medicines are not however aimed to kill the virus, but to stop it from multiplying. Adults are also advised to increase water intake to reduce dehydration and to relieve headaches. Painkillers such as paracetamol and ibuprofen are also recommended as they are effective in relieving itching and other symptoms such as fever or pains. Antihistamines may be used in cases when the symptoms cause the inability to sleep, as they are efficient for easing the itching and they are acting as a sedative. As with children, antiviral medication is considered more useful for those adults who are more prone to develop complications. These includepregnant women or people who have a poor immune system. Sorivudine, a nucleoside analogue has been found in few case reports effective in the treatment of primary varicella in healthy adults. Larger scale clinical trials are needed to demonstrate the efficacy of this medication.

PROGNOSIS The duration of the visible blistering caused by varicella zoster virus varies in children usually from 4 to 7 days, and the appearance of new blisters begins to subside after the 5th day. Chickenpox infection is milder in young children, and symptomatic treatment, with sodium bicarbonate baths or antihistamine medication may ease itching.

Paracetamol (acetaminophen) is widely used to reduce fever. Aspirin, or products containing aspirin, should not be given to children with chickenpox as it can cause Reye's syndrome.

In adults, the disease is more severe, though the incidence is much less common. Infection in adults is associated with greater morbidity and mortality due to pneumonia, hepatitis, and encephalitis. In particular, up to 10% of pregnant women with chickenpox develop pneumonia, the severity of which increases with onset later in gestation. In England and Wales, 75% of deaths due to chickenpox are in adults. nflammation of the brain, or encephalitis, can occur in immunocompromised individuals, although the risk is higher withherpes zoster. Necrotizing fasciitis is also a rare complication.

Secondary bacterial infection of skin lesions, manifesting as impetigo, cellulitis, and erysipelas, is the most common complication in healthy children. Disseminated primary varicella infection usually seen in the immunocompromised may have high morbidity. Ninety percent of cases of varicella pneumonia occur in the adult population. Rarer complications of disseminated chickenpox also include myocarditis, hepatitis, andglomerulonephritis.

Hemorrhagic complications are more common in the immunocompromised or immunosuppressed populations, although healthy children and adults have been affected. Five major clinical syndromes have been described: febrile purpura, malignant chickenpox with purpura, postinfectious purpura, purpura fulminans, and anaphylactoid purpura. These syndromes have variable courses, with febrile purpura being the most benign of the syndromes and having an uncomplicated outcome. In contrast, malignant chickenpox with purpura is a grave clinical condition that has a mortality rate of greater than 70%. The etiology of these hemorrhagic chickenpox syndromes is not known.

ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

The nose consists of the visible external nose and the internal nasal cavity. The nasal septum divides the nasal cavity into right and left sides. Air enters two openings, the external nares (nostrils; singular, naris), and passes into the vestibule and through passages called meatuses. The bony walls of the meatuses, called concha, are formed by facial bones (the inferior nasal concha and the ethmoid bone). From the meatuses, air then funnels into two (left and right) internal nares. Hair, mucus, blood capillaries, and cilia that line the nasal cavity filter, moisten, warm, and eliminate debris from the passing air.

The pharynx (throat) consists of the following three regions, listed in order through which incoming air passes:

The nasopharynx receives the incoming air from the two internal nares. The two auditory (Eustachian) tubes that equalize air pressure in the middle ear also enter here. The pharyngeal tonsil (adenoid) lies at the back of the nasopharynx.

The oropharyrnx receives air from the nasopharynx and food from the oral cavity. The palatine and lingual tonsils are located here.

The laryngopharynx passes food to the esophagus and air to the larynx.

The larynx receives air from the laryngopharynx. It consists of the following nine pieces of cartilage that are joined by membranes and ligaments.

The epiglottis, the first piece of cartilage of the larynx, is a flexible flap that covers the glottis, the upper region of the larynx, during swallowing to prevent the entrance of food.

The thyroid cartilage protects the front of the larynx. A forward projection of this cartilage appears as the Adam's apple.

The paired arytenoids cartilages in the rear are horizontally attached to the thyroid cartilage in the front by folds of mucous membranes. The upper vestibular folds (false vocal cords) contain muscle fibers that bring the folds together and allow the breath to be held during periods of muscular pressure on the thoracic cavity (straining while defecating or lifting a heavy object, for example). The lower vocal folds (true vocal cords) contain elastic ligaments that vibrate when skeletal muscles move them into the path of outgoing air. Various sounds, including speech, are produced in this manner.

The cricoid cartilage, the paired cuneiform cartilages, and the paired corniculate cartilages are the remaining cartilages supporting the larynx.

The trachea (windpipe) is a flexible tube, 10 to 12 cm (4 inches) long and 2.5 cm (1 inch) in diameter, whose wall consists of four layers, as shown in Figure2 :

The mucosa is the inner layer of the trachea. It contains mucusproducing goblet cells and pseudostratified ciliated epithelium. The movement of the cilia sweep debris away from the lungs toward the pharynx.

The submucosa is a layer of areolar connective tissue that surrounds the mucosa.

Hyaline cartilage forms 16 to 20 C-shaped rings that wrap around the submucosa. The rigid rings prevent the trachea from collapsing during inspiration.

The adventitia is the outermost layer of the trachea. It consists of areolar connective tissue.

The primary bronchi are two tubes that branch from the trachea to the left and right lungs.

Inside the lungs, each primary bronchus divides repeatedly into branches of smaller diameters, forming secondary (lobar) bronchi, tertiary (segmental) bronchi, and numerous orders of bronchioles (1 mm or less in diameter), including terminal bronchioles (0.5 mm in diameter) and microscopic respiratory bronchioles. The wall of the primary bronchi are constructed like the trachea, but as the branches of the tree get smaller, the cartilaginous rings and the mucosa are replaced by smooth muscle.

Alveolar ducts are the final branches of the bronchial tree. Each alveolar duct has enlarged, bubblelike swellings along its length. Each swelling is called an alveolus, and a cluster of adjoining alveolar is called an alveolar sac. Some adjacent alveoli are connected by alveolar pores.

The respiratory membrane consists of the alveolar and capillary walls. Gas exchange occurs across this membrane. Characteristics of this membrane follow:

Type I cells are thin, squamous epithelial cells that constitute the primary cell type of the alveolar wall. Oxygen diffusion occurs across these cells.

Type II cells are cuboidal epithelial cells that are interspersed among the type I cells. Type II cells secrete pulmonary surfactant (a phospholipid bound to a protein) that reduces the surface tension of the moisture that covers the alveolar walls. A reduction in surface tension permits oxygen to diffuse more easily into the moisture. A lower surface tension also prevents the moisture on opposite walls of an alveolus or alveolar duct from cohering and causing the minute airway to collapse.

Alveolar macrophage (dust cells) wander among the other cells of the alveolar wall removing debris and microorganisms.

A thin epithelial basement membrane forms the outer layer of the alveolar wall.

A dense network of capillaries surrounds each alveolus. The capillary walls consist of endothelial cells surrounded by a thin basement membrane. The basement membranes of the alveolus and the capillary are often so close that they fuse.

PATHOPHYSIOLOGY OF CHICKEN POX

PREDISPOSING FACTOR >childhood >occur at any age >socio economic status >environment >occupation

PRECIPITATING FACTOR >herpes virus varicellae

Invasion of virus or microorganism in the upper respiratory tract Viral proliferation occurs in regional lymph nodes Primary viremia (post infection 4-6 days) Second round of viral replication occurs in the bodys internal organ (liver & spleen) Secondary Viremia (14-16 days post infection) Diffuse viral invasion of capillary endothelial cell and the epidermis

Intracellular edema

intercellular edema

Macule Papule Vesicle Crust