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UGANDA NURSES AND MIDWIVES EXAMINATIONS BOARD
Year 1: Semester 1 Examinations | Diploma in Nursing Extension | Paper Code: DNE 113 | December 2019
SECTION A: Objective Questions (20 marks)
Remember to read each question carefully! The NOT questions require you to identify the FALSE statement. Take your time and eliminate wrong answers first.
For differential diagnosis questions, use the "SNAP" method: Symptoms, Nature, Associated features, Pattern
1
The commonest type of fracture found in children below 16 months is?
(d) Greenstick
A greenstick fracture is an incomplete fracture where the bone is bent and partially broken, much like a young, green twig breaks. This type of fracture is common in young children because their bones are softer, more flexible, and less brittle than adult bones. The periosteum (the outer lining of the bone) in children is also thicker and stronger, which often prevents the bone from breaking completely through.
💡 Pro Tip: Remember "GREEN" = children have "green" (young) bones that bend before they break completely!
2
Which of the following is the commonest site of osteomyelitis in children?
(d) Proximal extremities
Osteomyelitis in children most commonly affects the metaphysis of long bones (femur, tibia, humerus). These are major bones of the "proximal extremities" - the limbs and specifically their long bones. The rich blood supply in the metaphyseal region makes them susceptible to hematogenous (blood-borne) spread of infection.
OSTEOMYELITIS SITES: "MEAT" - Metaphysis, Epiphysis (neonates), After trauma, Tubular bones
3
The most important nursing consideration when managing a child with osteogenesis imperfecta is to
(c) handle the child carefully
Osteogenesis imperfecta (OI), or brittle bone disease, is characterized by fragile bones that fracture easily. The utmost priority is handling the child with extreme care and gentleness to prevent iatrogenic fractures. This includes careful positioning, lifting, dressing, and diapering. Every interaction requires gentle technique.
⚠️ Critical Safety: Even gentle handling can cause fractures in OI. Always use minimal force, support limbs fully, and avoid sudden movements!
4
Which of the following is NOT a sign of airway obstruction?
(c) Convulsion
A convulsion (seizure) is primarily a neurological event characterized by abnormal electrical activity in the brain. While severe airway obstruction can lead to hypoxia which may eventually trigger a convulsion, it is NOT a direct sign of airway obstruction. The other options are classic respiratory distress signs.
🧠 Remember: Convulsion is a LATE complication of severe hypoxia, not an early sign of airway obstruction itself.
5
Which of the following is NOT a principle indication for tracheostomy?
(b) Cardiac arrest
Cardiac arrest is the sudden cessation of heart function. The immediate priority is CPR (chest compressions and rescue breathing via bag-mask ventilation or endotracheal intubation). A tracheostomy is a surgical procedure, not an emergency airway management technique for acute cardiac arrest. While a patient may later need tracheostomy for prolonged ventilation, it's not the immediate intervention.
🚨 Emergency Airway: In cardiac arrest, use endotracheal intubation or bag-mask ventilation - NOT tracheostomy!
6
The most appropriate nursing diagnosis for a child with productive cough would be
(c) ineffective airway clearance
A productive cough means the child is coughing up mucus/sputum. The nursing diagnosis "Ineffective Airway Clearance" is defined as inability to clear secretions from the respiratory tract. A productive cough is a direct sign the child is attempting to clear secretions - if difficult or excessive, their airway clearance is ineffective.
COUGH DIAGNOSIS: Productive = Clearance problem, Dry = Irritation/Pattern problem
7
Which of the following is a congenital heart defect NOT found in tetralogy of Fallot?
(d) Aortic stenosis
Tetralogy of Fallot (TOF) includes: 1) VSD, 2) Pulmonary stenosis, 3) Overriding aorta, 4) Right ventricular hypertrophy. Aortic stenosis is NOT one of the four defects. TOF involves narrowing of the pulmonary outflow tract, not the aortic valve.
❤️ TOF Formula: "PROVe" = Pulmonary stenosis, Right ventricular hypertrophy, Overriding aorta, Ventricular septal defect
8
Which of the following poses the greatest risks of HIV infection in infants?
(b) Mixed feeding
Mixed feeding (breast milk + other foods/liquids before 6 months) poses the HIGHEST risk. Other foods disrupt the infant's gut lining, making it more permeable and susceptible to HIV entry from breast milk. WHO recommends exclusive breastfeeding for HIV+ mothers on ART, or exclusive formula feeding if AFASS criteria are met. Mixed feeding should be AVOIDED.
INFANT FEEDING: "EME" - Exclusive (lowest risk if ART), Mixed (HIGHEST risk), Exclusive formula (zero risk if safe)
9
Purulent discharge from the eyes of a new born baby within 21 days of birth is due to
(a) opthalmia neonatorum
Ophthalmia neonatorum is defined as conjunctivitis occurring in a newborn, typically within the first month of life. It's characterized by purulent discharge, often from bacterial infections (Neisseria gonorrhoeae, Chlamydia trachomatis) acquired during birth.
👶 Newborn Eye Care: Ophthalmia neonatorum requires immediate treatment to prevent blindness. Prophylactic eye drops at birth are standard!
10
Which of the following is the most common site for inhaled foreign objects to become dislodged?
(c) Primary bronchi
The right primary bronchus is the most common site. It's wider, shorter, and more vertical (straighter line from trachea) than the left, making it an easier path for aspirated objects. Most foreign bodies lodge in one of the main bronchi.
FOREIGN BODY: "RIGHT" = Right bronchus Is Generally Highest-risk Territory
11
Which of the following is a result of increased intra ocular pressure?
(d) Glaucoma
Glaucoma is a group of eye conditions where increased intraocular pressure (IOP) damages the optic nerve, causing progressive vision loss. While some glaucoma types have normal pressure, elevated IOP is the hallmark risk factor and defining feature of most glaucoma cases.
👁️ Glaucoma = "Silent Thief of Sight": Regular IOP screening after age 40 is crucial as vision loss is irreversible!
12
Which of the following may NOT cause epistaxis?
(d) Hypertension (with nuance)
While all options can be associated with epistaxis, hypertension is the least direct cause. Severe hypertension can lead to epistaxis, but it's often considered an associated factor or exacerbator rather than a primary local cause like trauma, septal deviation, or sinusitis which directly affect nasal mucosa integrity.
🤔 Nuance Alert: Hypertension is debated as a direct cause but is definitely a risk factor for more severe bleeding once it starts!
13
Which of the following is a first aid intervention for a child with epistaxis?
(c) Pinch the nose and instruct the child to bend forward
Correct first aid: 1) Child sits up and leans slightly forward (prevents blood draining down throat → choking/nausea), 2) Firmly pinch the soft fleshy part of the nose just below the bony bridge continuously for 10-15 minutes. This combination is the gold standard first aid.
EPITAXIS FIRST AID: "LEAN" - Lean forward, Elevate (pinch), Apply pressure, No lying down
14
Which of the following refers to the sickle cell crisis in which there is pooling of blood in the spleen?
(a) Sequestration
Splenic sequestration crisis is a LIFE-THREATENING complication where sickle cells get trapped in the spleen, causing rapid splenomegaly. This traps a large portion of blood volume in the spleen, leading to sudden severe anemia and potential hypovolemic shock. Most common in young children (before autoinfarction of spleen).
🚨 Emergency! Splenic sequestration can cause death within hours. Look for: sudden pallor, abdominal distension, shock, rapidly enlarging spleen. Requires immediate transfusion!
15
The most common cause of respiratory distress syndrome in the first 24 hours of birth is
(b) Meconium aspiration
Meconium Aspiration Syndrome (MAS) is a major cause of severe respiratory distress in term/post-term infants who pass meconium in utero and aspirate it. It causes chemical pneumonitis, airway obstruction, and can lead to persistent pulmonary hypertension. Symptoms begin shortly after birth. Classic RDS from surfactant deficiency is most common in premature infants.
👶 Population Matters: In PRETERM infants, surfactant deficiency is #1. In TERM infants, MAS and TTN are most common causes of respiratory distress.
16
Which of the following is NOT a clinical feature of otitis media?
(c) Tinnitus
While tinnitus can occur with some ear conditions (otitis media with effusion, chronic OM), it's less commonly reported as a primary feature of acute otitis media (AOM), especially in young children who can't describe it. Fever, ear pain (otalgia), and pus discharge (if eardrum perforates) are hallmark AOM features.
👂 Key Distinction: Tinnitus is more characteristic of chronic or serous OM, not acute bacterial OM where pain and fever dominate.
17
Which of the following conditions has a genetic basis?
(c) Sickle cell disease
Sickle cell disease is an inherited genetic disorder of hemoglobin. It's caused by a mutation in the gene that makes hemoglobin, following an autosomal recessive inheritance pattern. The other conditions are primarily acquired from environmental factors (diet, infection, medications).
GENETIC vs ACQUIRED: "SICKLE" is Genetic, "DIGESTIVE" issues are mostly Acquired
18
The commonest causative organism for tonsillitis in children belong to
(d) Streptococci
The most common bacterial cause of acute tonsillitis in children is Group A Streptococcus (GAS) - Streptococcus pyogenes, also known as "strep throat." While viruses are also very common, when bacterial, Streptococci predominate.
🔬 Strep Throat Classic Triad: Fever, Tonsillar exudates, Tender anterior cervical lymph nodes (no cough)!
19
The most appropriate nursing management of a child in sickle cell crisis involves;
(c) analgesics and blood transfusion
Analgesics are paramount for pain relief in vaso-occlusive crisis (VOC). Blood transfusions are critical for specific severe complications (severe anemia, acute chest syndrome, stroke, splenic sequestration). This combination addresses both the universal symptom (pain) and major life-threatening complications.
SICKLE CRISIS CARE: "PATH" - Pain relief, Analgesics, Transfusion (if indicated), Hydration
20
Contact with which of the following HIV infected materials should be considered eligible for post exposure prophylaxis treatment?
(c) Broken skin exposed to small volume of amniotic fluid
Amniotic fluid is considered potentially infectious for HIV. Exposure of broken skin (non-intact skin) to amniotic fluid constitutes a significant exposure warranting PEP consideration. The risk increases with volume and viral load. This is a clear-cut indication for PEP assessment.
⚠️ PEP Criteria: Non-intact skin or mucous membrane exposure to blood, amniotic fluid, breast milk (if bloody), cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, or vaginal secretions from HIV+ source.
SECTION B: Fill in the Blank Spaces (10 marks)
21
An abnormal discharge of mucus from the nose is termed as __________
Rhinorrhea
Rhinorrhea is the medical term for a runny nose, characterized by free discharge of thin nasal mucus. From Greek: "rhino-" (nose) + "-rrhea" (flow/discharge).
22
A condition of increased pressure within the eyeball, causing gradual loss of sight is called __________
Glaucoma
Glaucoma is a group of eye diseases that damage the optic nerve, often characterized by increased intraocular pressure. If untreated, it causes gradual, irreversible vision loss, typically starting with peripheral vision.
23
An abnormal feeling of rotation of one's head due to disease affecting the vestibular nerve of the ear is known as __________
Vertigo
Vertigo is a sensation of spinning dizziness, as if the room or oneself is revolving. Often caused by problems with the inner ear (including vestibular nerve), brain, or sensory nerve pathways.
24
Patients with short sightedness are suffering from a condition called __________
Myopia
Myopia (near-sightedness) is a refractive error where distant objects appear blurred. Occurs when eyeball is too long or cornea/lens too curved, causing light to focus in front of retina instead of directly on it.
25
Inflammation of the cornea and iris of the eye is termed as __________
Keratoiritis
Keratoiritis (or iridocyclitis with keratitis/anterior uveitis with keratitis). Keratitis = cornea inflammation, iritis = iris inflammation. Keratoiritis specifically indicates both are inflamed.
26
A severe chronic blood disorder in which the red blood cells have abnormal shape and do not carry normal hemoglobin is referred to as __________
Sickle cell anemia (or Sickle cell disease)
Sickle cell anemia is an inherited blood disorder where red blood cells become crescent-shaped. Abnormal hemoglobin S causes cells to block blood flow, causing pain and organ damage, and break down rapidly causing chronic anemia.
27
Inflammation of the lung parenchyma in children is called __________
Pneumonia
Pneumonia is infection that inflames the air sacs (alveoli, part of lung parenchyma) in one or both lungs. Air sacs may fill with fluid or pus, causing cough with phlegm/pus, fever, chills, and difficulty breathing.
28
Increased respiratory rate noted in children with respiratory distress is termed as __________
Tachypnea
Tachypnea is the medical term for abnormally rapid breathing. Common sign of respiratory distress in children as the body compensates for inadequate oxygen intake or tries to eliminate excess carbon dioxide.
29
A type of traction applied on a child when both legs are extended vertically to reduce fracture of femur is termed as __________
Bryant's traction (also known as Gallow's traction)
Bryant's traction is skin traction used for femur fractures or congenital hip dislocations in young children (<2 years or <12-14kg). Both legs are suspended vertically at 90° to hips, with buttocks slightly elevated, using child's body weight for countertraction.
30
Continued incontinence of urine past the age of toilet training is termed as __________
Enuresis
Enuresis is involuntary urination in children past age when bladder control is expected (typically >5 years). Can be diurnal (day) or nocturnal (night/bedwetting).
SECTION B: Short Essay Questions (10 marks)
31
Outline five (5) common signs and symptoms of nephrotic syndrome in children. (5 marks)
Nephrotic syndrome is characterized by massive protein loss due to glomerular damage. Common features include:
1. Massive Proteinuria: >3.5g/day in adults or >40 mg/m²/hr in children. Urine appears foamy/frothy due to protein loss. Damaged glomeruli lose ability to prevent protein passage.
2. Generalized Edema (Anasarca): Starts periorbitally (puffy eyes), then dependent areas (ankles), eventually ascites and pleural effusion. Caused by hypoalbuminemia reducing plasma oncotic pressure, plus sodium/water retention.
3. Hypoalbuminemia: Serum albumin <2.5 g/dl due to massive urinary loss. Body can't synthesize albumin fast enough to replace losses.
4. Hyperlipidemia: Elevated cholesterol and triglycerides. Liver increases lipoprotein synthesis in response to low oncotic pressure; reduced plasma oncotic pressure stimulates hepatic lipoprotein synthesis.
5. Increased Susceptibility to Infections: Loss of immunoglobulins and complement factors in urine weakens immune system. Edematous tissues are also more infection-prone. Steroid treatment further immunosuppresses.
NEPHROTIC SYNDROME: "PHEW" - Proteinuria, Hypoalbuminemia, Edema, Weight gain
32
Outline five (5) ways of preventing the transmission of trachoma in the community. (5 marks)
Trachoma (Chlamydia trachomatis) prevention uses WHO's SAFE strategy:
1. Surgery for Trichiasis: Correct inturned eyelashes to prevent corneal damage and reduce infectious reservoir. Stops constant corneal abrasion and associated discomfort that leads to eye rubbing and spread.
2. Antibiotics: Mass drug administration (MDA) of azithromycin or tetracycline eye ointment to entire endemic communities. Treats active infection and reduces community burden by targeting both symptomatic and asymptomatic carriers.
3. Facial Cleanliness: Regular face washing with soap and water, especially for children. Removes bacteria-laden discharge, reducing infection source and making faces less attractive to eye-seeking flies.
4. Environmental Improvement: Provide clean water access, improve sanitation (latrines), and implement fly control. Reduces fly breeding sites and enables hygiene practices. Eye-seeking flies (Musca sorbens) breed in exposed feces.
5. Health Education: Community education about trachoma transmission and prevention in culturally sensitive manner. Empowers behavior change, promotes hygiene practices, and encourages early treatment seeking.
TRACHOMA PREVENTION: "SAFE" = Surgery, Antibiotics, Facial cleanliness, Environmental improvement
SECTION C: Long Essay Questions (60 marks)
33
(a) Outline ten (10) specific interventions nurses should implement for a patient within the first 4 hours of tonsillectomy. (10 marks)
(b) Outline ten (10) nursing interventions that should be implemented during the immediate care of a patient who has undergone cataract surgery. (10 marks)
(b) Outline ten (10) nursing interventions that should be implemented during the immediate care of a patient who has undergone cataract surgery. (10 marks)
(a) First 4-Hour Post-Tonsillectomy Nursing Interventions:
Post-tonsillectomy care focuses on airway management, bleeding observation, pain control, and hydration:
1. Maintain Patent Airway: Position patient on side (lateral) or semi-prone with head slightly lowered once awake. Allows drainage of saliva/mucus/blood, preventing aspiration. Avoid supine position.
2. Monitor Vital Signs Frequently: Check pulse, respirations, BP, SpO2 every 15 min for first hour, then every 30 min. Tachycardia, hypotension, tachypnea signal hemorrhage/shock; decreased SpO2 indicates respiratory compromise.
3. Observe for Bleeding (Hemorrhage): Watch for frequent swallowing (key sign of blood trickling), inspect vomitus for fresh bright red blood (dark old blood is common), note restlessness/anxiety/pallor. Early detection crucial for prompt intervention.
4. Assess and Manage Pain: Administer prescribed analgesics (paracetamol, ibuprofen, opioids if needed) regularly using age-appropriate pain scale. Adequate pain control promotes comfort, encourages fluid intake, reduces restlessness.
5. Encourage Clear Fluid Intake: Offer sips of cool, clear, non-acidic, non-carbonated fluids (water, diluted apple juice, ice chips) once awake and gag reflex present. Avoid red/brown fluids to distinguish from blood if vomiting occurs.
6. Apply Ice Collar: Apply ice collar/cold pack to neck if available and tolerated. Vasoconstriction minimizes edema and provides analgesic effect.
7. Monitor for Nausea/Vomiting: Administer antiemetics as prescribed. Vomiting increases pain and can dislodge clots at surgical site, increasing bleeding risk.
8. Discourage Coughing/Throat Clearing: Advise patient/parents to avoid these actions which can dislodge clots from tonsillar fossae and precipitate bleeding.
9. Provide Gentle Oral Hygiene: If tolerated, allow gentle mouth rinses with plain cool water later in period, but avoid aggressive gargling that could disturb surgical site.
10. Educate on Warning Signs: Clearly instruct patient/parents to report immediately: spitting bright red blood, frequent swallowing, vomiting fresh blood, extreme restlessness - empowers participation in care.
(b) Immediate Post-Cataract Surgery Nursing Interventions:
Cataract surgery post-op care focuses on safety, comfort, preventing complications (infection, increased IOP, injury) and education:
1. Monitor Vital Signs: Check BP, pulse, respirations per PACU protocol to ensure cardiovascular/respiratory stability after anesthesia (local or general).
2. Assess Level of Consciousness: Especially if sedation/general anesthesia used. Ensure patient is alert/responsive for safety.
3. Check Eye Dressing/Shield: Ensure eye pad and shield are secure and properly in place. Do not remove unless specifically instructed. Protects operated eye from rubbing, pressure, injury.
4. Assess for Pain and Administer Analgesia: Mild discomfort/scratchy feeling is common; severe pain is not and should be reported. Administer mild analgesics (paracetamol) as prescribed.
5. Assess for Nausea/Vomiting: Administer antiemetics as prescribed. Vomiting can increase intraocular pressure, which is undesirable after eye surgery.
6. Position Appropriately: Advise patient to avoid lying on operated side. Usually back or non-operated side is recommended. Elevate head of bed slightly (30°) to reduce intraocular pressure.
7. Reinforce Post-Op Instructions: Verbally and in writing: eye drop administration, activity restrictions (no bending, lifting, straining), hand hygiene, eye shield use (at night), complication warning signs, follow-up appointments.
8. Monitor for Immediate Complications: Observe for excessive bleeding/discharge, sudden sharp pain, or sudden vision loss. Report immediately to surgeon for prompt intervention.
9. Offer Light Refreshments: Once stable, alert, and able to tolerate oral intake, offer light refreshments if NPO before procedure - provides comfort and hydration.
10. Ensure Safe Discharge: Confirm responsible adult escort home. Vision will be blurry and patient may be drowsy - driving/navigating alone is unsafe.
POST-OP EYE CARE: "WATCH" - Wound check, Activity restriction, Teach, Check pressure, Help with discharge
34
(a) Outline six (6) of the nurses concerns for a child brought in with respiratory distress syndrome. (6 marks)
(b) Outline, with rationale, seven (7) specific nursing interventions that should be implemented for a child admitted with status asthmaticus. (14 marks)
(b) Outline, with rationale, seven (7) specific nursing interventions that should be implemented for a child admitted with status asthmaticus. (14 marks)
(a) Nurse's Concerns for Child with Respiratory Distress Syndrome:
Critical concerns focus on maintaining life and preventing deterioration:
1. Inadequate Oxygenation and Hypoxia: Primary concern - is child getting enough O₂? Signs: cyanosis, low SpO₂, altered mental status (irritability, lethargy). Hypoxia rapidly causes cellular damage, organ dysfunction (especially brain/heart), and can be fatal.
2. Impaired Gas Exchange (Ventilation Failure): Can child effectively remove CO₂? Signs: CO₂ retention (hypercapnia) leading to lethargy, decreased responsiveness, respiratory acidosis. Ineffective ventilation depresses cardiac/neurological function.
3. Increased Work of Breathing and Fatigue: Observe tachypnea, nasal flaring, grunting, accessory muscle use, retractions. Concern: child will tire from excessive effort, leading to respiratory muscle fatigue and arrest.
4. Airway Patency and Potential Obstruction: Is airway open/clear? Listen for stridor (upper airway obstruction), wheezing (lower airway narrowing), gurgling (secretions). Compromised airway prevents O₂ entry/CO₂ removal - medical emergency.
5. Potential for Rapid Deterioration and Respiratory Arrest: Children have limited reserves; condition can worsen quickly. Constant vigilance for subtle changes indicating impending respiratory failure is essential for timely escalation of care.
6. Identifying Underlying Cause and Complications: While supporting care is paramount, nurse must consider cause (pneumonia, asthma, foreign body, sepsis, heart failure) and watch for complications like pneumothorax. Treating cause is essential for resolution.
(b) Nursing Interventions for Status Asthmaticus (with Rationale):
Status asthmaticus is a severe, prolonged asthma attack unresponsive to standard bronchodilators - life-threatening emergency:
1. Administer High-Flow Oxygen Therapy: Provide humidified O₂ via face mask (non-rebreather if severe) or nasal cannula to maintain SpO₂ >94%. Status asthmaticus causes severe bronchoconstriction/inflammation leading to hypoxia. Supplemental O₂ corrects hypoxemia, improves tissue oxygenation, reduces work of breathing. Humidification prevents secretion drying.
2. Administer Rapid-Acting Inhaled Bronchodilators Frequently: Give short-acting beta2-agonists (SABA) like Salbutamol via nebulizer, often continuously or every 20 minutes for first hour. May add ipratropium bromide. SABAs relax bronchial smooth muscle → bronchodilation. Anticholinergics provide additive effect. Frequent administration needed due to severity.
3. Administer Systemic Corticosteroids: Give oral prednisolone or IV hydrocortisone/methylprednisolone as prescribed WITHOUT delay. Corticosteroids reduce airway inflammation/edema and decrease mucus production. Effect takes hours but crucial for treating underlying inflammation and preventing relapse. Early administration is key.
4. Establish and Maintain IV Access: Secure IV access promptly for fluids and medications. Administer IV fluids (isotonic saline). IV access essential for emergency meds (IV steroids, magnesium sulfate, aminophylline) and rehydration. Children may be dehydrated from tachypnea, decreased intake, vomiting. IV fluids correct dehydration and keep secretions loose.
5. Perform Continuous Cardiorespiratory Monitoring: Continuously monitor HR, RR, BP, SpO₂. Frequent respiratory assessments: auscultate breath sounds (wheezing, air entry), work of breathing (retractions, flaring, accessory muscles), level of consciousness. Note "silent chest" (ominous sign of severe obstruction). Close monitoring allows early detection of worsening status, treatment response, or complications (fatigue, impending arrest, pneumothorax).
6. Position for Optimal Lung Expansion: Assist child into position of comfort that facilitates breathing - usually upright (sitting up, leaning forward on table - "tripod position"). Avoid forcing flat. Upright position allows maximum diaphragmatic excursion and lung expansion, reducing work of breathing. Comfort position minimizes distress.
7. Provide Calm, Reassuring Environment: Maintain calm demeanor, explain procedures simply, reassure child and parents, allow parents to stay if possible. Anxiety and fear exacerbate bronchoconstriction and increase work of breathing/O₂ demand. Calm environment and support reduce anxiety, promoting better cooperation with treatments.
STATUS ASTHMATICUS: "OXYGEN" - O₂, bronchodilatoRs, Corticosteroids, IV access, monitoRing, Positioning, Emotional support, Non-stop monitoring
35
(a) List five (5) signs and symptoms that commonly occur in HIV infected children. (5 marks)
(b) Outline fifteen (15) interventions that should be implemented during management of a child admitted in sickle cell crisis until discharge. (15 marks)
(b) Outline fifteen (15) interventions that should be implemented during management of a child admitted in sickle cell crisis until discharge. (15 marks)
(a) Common Signs/Symptoms in HIV-Infected Children:
HIV in children manifests through immune dysfunction and opportunistic infections:
1. Failure to Thrive (FTT) / Poor Weight Gain and Growth Delay: Difficulty gaining weight and growing normally due to poor appetite, malabsorption, chronic infections, increased metabolic demands. HIV affects nutrient absorption/utilization.
2. Recurrent or Persistent Infections: Weakened immune system causes frequent/severe/unusual infections: persistent oral thrush (candidiasis), recurrent bacterial infections (pneumonia, otitis media, sinusitis, skin infections), persistent diarrhea, opportunistic infections like Pneumocystis jirovecii pneumonia in severe immunosuppression. HIV destroys CD4+ T-lymphocytes crucial for immune defense.
3. Generalized Lymphadenopathy: Persistent, widespread swollen lymph nodes in neck, armpits, groin. Lymph nodes become reactive as body fights chronic HIV infection and co-infections.
4. Hepatosplenomegaly: Enlarged liver and spleen due to body's response to chronic infection, direct viral effects, or involvement with opportunistic conditions.
5. Developmental Delay or Neurological Problems: HIV affects developing brain, causing delays in milestones (sitting, walking, talking). May develop progressive encephalopathy, seizures, motor deficits. HIV infects brain cells or causes CNS inflammation.
(b) Interventions for Child in Sickle Cell Crisis (Admission to Discharge):
Comprehensive management involves pain relief, complication management, supportive care, education, and discharge planning:
1. Prompt Pain Assessment and Management: Regularly assess pain using age-appropriate scale. Administer prescribed analgesics (NSAIDs, paracetamol, opioids like morphine) on schedule and PRN for breakthrough pain. Add non-pharmacological methods (heat packs, distraction). Pain is hallmark of vaso-occlusive crisis (VOC); effective relief is priority for comfort and stress reduction.
2. Ensure Adequate Hydration: Administer IV fluids (D5W with 0.25% or 0.45% saline) at maintenance or higher rate. Encourage oral fluids if tolerated. Monitor intake/output. Hydration reduces blood viscosity, improves microvascular perfusion, reduces sickling and vaso-occlusion.
3. Administer Oxygen Therapy as Indicated: Monitor SpO2. Give supplemental O₂ via nasal cannula or face mask if SpO₂ <92-94% or signs of hypoxia/acute chest syndrome. Hypoxia promotes sickling; O₂ therapy corrects hypoxemia and improves tissue oxygenation.
4. Monitor Vital Signs and Respiratory Status: Regularly check temperature, pulse, respirations, BP, SpO2. Assess for respiratory distress (tachypnea, cough, chest pain, retractions) indicating acute chest syndrome (ACS). Early detection of complications like infection, ACS, cardiovascular instability.
5. Administer Antibiotics if Infection Suspected: Give broad-spectrum antibiotics if fever present or infection suspected (common crisis trigger), pending cultures. Children with SCD are prone to infections; prompt treatment crucial as infection can precipitate/worsen crisis.
6. Facilitate Blood Transfusions as Prescribed: If ordered for severe anemia, ACS, stroke, splenic sequestration, prepare and administer transfusions safely, monitoring for reactions. Transfusions increase normal RBC proportion, improve O₂-carrying capacity, reduce sickle cells, alleviating complications.
7. Monitor for Complications: Vigilantly assess for ACS (chest pain, fever, cough, infiltrate), stroke (neurological changes), splenic sequestration (sudden pallor, abdominal distension, shock), aplastic crisis (severe Hb drop), priapism, DVT. Early detection allows prompt specific interventions.
8. Provide Folic Acid Supplementation: Administer daily folic acid as prescribed. Chronic hemolysis increases RBC turnover, requiring more folic acid for new red cell production.
9. Promote Rest and Comfort: Minimize disturbances, position child comfortably, encourage rest periods. Rest reduces metabolic demands and O₂ consumption, beneficial during crisis. Comfort measures aid pain management.
10. Maintain Optimal Body Temperature: Keep child warm, avoid cold exposure (precipitates sickling), manage fever with antipyretics. Cold triggers vasoconstriction and increased sickling; fever increases metabolic demand and fluid loss.
11. Provide Psychosocial Support: Offer emotional support, listen to concerns, provide clear explanations, involve child life specialists. Hospitalization and pain are very stressful; support helps child and family cope.
12. Educate on Crisis Prevention: Reinforce knowledge about triggers (dehydration, infection, cold, stress), importance of hydration, prophylactic medications (penicillin, hydroxyurea), recognizing early signs, when to seek care. Empowers family to manage effectively at home and prevent future crises.
13. Ensure Adequate Nutrition: Encourage balanced diet when tolerated, monitor appetite and intake. Good nutrition supports overall health and immune function important in chronic condition.
14. Coordinate Multidisciplinary Care: Liaise with doctors, hematologists, physiotherapists, social workers for comprehensive care. Team approach ensures all aspects of child's care addressed.
15. Prepare for Discharge: Ensure pain controlled on oral analgesics, afebrile, tolerating oral fluids, stable. Confirm follow-up appointments, provide prescriptions, ensure family understands discharge plan and home care instructions. Well-planned discharge ensures smooth transition to home care.
SICKLE CELL CARE: "PAINFREE" - Pain control, Analgesics, IV fluids, Nutrition, Fluids, Rest, Education, Emotional support
🏥 Discharge Criteria: Pain controlled orally, afebrile >24 hours, tolerating diet, no complications, family educated, follow-up arranged, prophylactic antibiotics continued!