STTI, Case SN0009, Complications of Chicken Pox - Acute Hepatitis and Acute Dehydration

Meet the Author

Title	Complications of Chicken Pox - Acute Hepatitis and Acute Dehydration Case Study SN0009
Author	Julee Waldrop, RNCS, MS, FNP, PNP
Contact Hours	1.4
Target Audience:	Pediatric Nurses, Public Health Nurses, Family Practice Nurses, Nurse Practitioners and other Advanced Practice Nurses
Purpose/Goal:	The nurse will be able to describe the possible complications of varicella including the importance of prevention.

Objectives	Physical Exam Findings
Instructions	Laboratory/Test Data
Introduction	Course of Care
Medical/Nursing History	References
Family or Social History	TEST QUESTIONS

Sigma Theta Tau International is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation.

Julee Waldrop, RNCS, MS, FNP, PNP
Julee Waldrop has recently joined the faculty of the School of Nursing the University of North Carolina at Chapel Hill as a clinical assistant professor in the Pediatric Nurse Practitioner program. She holds a BA in Education from the University of North Carolina (1981) and a BSN from Texas Women's University (1986). She practiced in various staff, educator, and management positions in in-patient care before earning her Masters Degree and Family Nurse Practitioner certification in 1991. She practiced for ten years at Carle Clinic Association in Champaign, Illinois as well as teaching at the University of Illinois Chicago's regional site in Urbana in the Family Nurse Practitioner and the BSN programs. She earned her Pediatric Nurse Practitioner certificate in 1994 and has been practicing as a primary care pediatric nurse practitioner with special interest in immunizations, asthma, and adolescent gynecology. She was inducted into Sigma Theta Tau in 1986. She is a Fellow in the National Association of Pediatric Nurse Practitioners (NAPNAP). She enjoys writing and writes a monthly column and is a contributing editor for The Clinical Advisor for Nurse Practitioners.

Instructions

Medical/Nursing History:
Upon admission to the pediatric intermediate care unit after surgery, the nurse caring for Anita collected the following information.

Prenatal History
Mother’s first pregnancy; uneventful and without complications.

Delivery
Spontaneous vaginal delivery without problems in the perinatal period.

Health History
No history of chronic illness or hospitalization. Has suffered occasional upper respiratory infections and otitis media. Has received all of the recommended childhood immunizations except for the varicella vaccine. Her mother reported that her physician did not feel that it was a necessary vaccine at the time.

Family or Social History:
Anita is the only child of a single mother who works as a certified nursing assistant. She has an extended family involved in her life, which includes her maternal grandmother and her maternal great grandmother. All of them were present at various times during her hospital stay. Her father sees her occasionally but had not been present in the hospital.

Developmental Assessment
Mother reports the patient feeds herself and helps with dressing, rides a tricycle and alternates feet when going up stairs. Likes to color, play with dolls, and do puzzles. Patient can speak clearly in complete sentences; mother has no problems understanding what patient says.

Response to Hospitalization
The patient has had many painful and threatening procedures performed since her admission and is very fearful of anyone touching her at present. Her mother is very helpful in calming the patient and assisting the staff with procedures.

Physical Examination Findings:
Vital Signs
Respirations 28, Pulse 98 radial, BP 90/50 R arm, supine, Temperature 99.8°F axillary, Height 36 inches, Weight 31 lb 9 oz.

Integument
Multiple healing lesions noted over entire body - most were approximately 2-5 mm in size, slightly erythematous, and either crusting or with scabs. Skin pale underneath dark skin tone. Temperature warm to touch and dry. Skin turgor poor on admission with slight tenting at sternum but improved at present. Capillary refill >3 sec on admission and < 3 sec at present.

Head and Neck
Head: No masses palpated. Healing lesions on face and scalp. Facial features symmetrical. Eyes: Clear and PERRLA (Pupils Equal Round Reactive to Light and Accommodation), EOM (extraocular muscles) intact and no nystagmus. Ears: Normal configuration, tympanic membranes pearl gray with positive light reflexes and good mobility. Nose: Nasal mucosa erythematous and swollen with clear exudate. Throat: Clear, no oral lesions or tonsillar hypertrophy. Neck: Supple, full range of motion and strength.

Lymphatics
Mild, patchy lymphadenopathy of anterior and posterior cervical lymph node chains (0.5 cm). Left axillary lymphadenopathy (1.0 cm). Bilateral inguinal lymphadenopathy (1.5 cm).

Respiratory
Lungs clear with no adventitious sounds.

Cardiovascular
Heart rate 96, rhythm regular, no murmurs. Peripheral pulses 2+ and equal bilaterally.

Abdominal
Bowel sounds present but hypoactive in all four quadrants. Per OR nurse, abdomen was tender to light palpation especially in the right upper quadrant. Liver margin palpable at 2 cm below the costal margin and percussed at 5 cm. Spleen non-palpable and non-tender. Currently a dressing was in place in the upper right quadrant, 3 cm area of serosanguineous appearing drainage circled about 2 hours ago. Ascites noted using ballottement technique.

Genitourinary
Foley catheter in place, draining dark amber urine. External genitalia normal in appearance except for a few healing lesions similar in appearance to those on the rest of her body on her labia and buttocks. Negative CVA tenderness.

Extremities
Moves all extremities equally. Strength: Grade five on the Lovett scale in all extremities except the left forearm where the swelling was causing her discomfort. Left forearm was erythematous and tender to palpation. Edema was non-pitting. Left forearm maximum circumference was 9 cm and right forearm was 7 cm.

Neurological Assessment
CN II-XII (cranial nerves) grossly intact. DTR’s (deep tendon reflexes) 2+ bilaterally. Communicates and responds appropriately for her age to questions and situations.

*All lab values are for children.
**Previously referred to as serum glutamic oxaloacetic transaminase (SGOT) (Cavanaugh, 1999)

Course of Care:
It was initially thought that this patient was suffering from appendicitis, and therefore she underwent exploratory abdominal surgery with the resultant removal of her appendix, which was not infected or inflamed. After surgery it was determined, based on her lab work and further consideration of her history, that she was suffering from complications of varicella: acute hepatitis, local cellulitis and severe dehydration (Bovill & Bannister, 1998). The Center for Disease Control’s Web site offers additional information about complications of chicken pox. There is one published study of primary disseminated varicella that presented as acute abdominal pain (Kim & Haycox, 1999).

Varicella is caused by the varicella-zoster virus (VZV). It is very contagious. In healthy children most cases of varicella are mild. Symptoms include the classic vesicular-pustular rash, fever, malaise, and urticaria associated with the lesions. The illness usually lasts about five to seven days and is self-limited (Costello, 1999).

Though the varicella vaccine has been available since 1995, potential barriers to vaccination identified by the CDC (Centers for Disease Control) include perception that varicella is mild and vaccination is not warranted, concerns about long-lasting immunity and effectiveness of the vaccine, stringent vaccine storage and handling requirements (Varivax must be frozen until it is reconstituted for injection, and the vaccine must be discarded 30 minutes after reconstitution.), vaccine availability and cost, and inadequate insurance coverage (Costello, 1999).

Management of this patient includes both medical and nursing issues.

Rehydration
Upon admission the patient was severely dehydrated with an estimated 10 percent body weight loss. She received fluid resuscitation, and since surgery her fluid status has improved with an increase in her urinary output. The patient is currently receiving D5 1/2NS at 50 cc/hr. Strict I & O is also ordered.

Pain Management
To control pain, the patient is receiving morphine (.15 mg at 10 min intervals; max 3.6 mg/4hr) per PCA and has Tylenol (acetaminophen) (210 mg q 3-4 hours) ordered for later. She also has Benadryl (diphenhydramine) 25 mg ordered for itching (possible side effect of morphine) prn.

Post-op Care
Care was for that of a general surgical patient and included airborne and contact isolation. Universal precautions are needed until the diagnosis of varicella is confirmed. The contagious period for varicella is approximately 2 days before lesions appear until they have crusted over. At this time, all lesions are crusted over so contagion is unlikely. If the lesions were still active, once varicella infection became part of the diagnosis, respiratory precautions should be taken for anyone who has not been vaccinated for chicken pox or had the disease.

Activity was as tolerated and diet ad lib. Because of possible electrolyte imbalance, she was placed on a cardiac monitor and continuous pulse oximetry.

Varicella management
Although varicella infection is the initiating event in this patient’s current illness, there is no specific therapy that can be used to improve her condition at this point.

Infection
Although her varicella infection and her hepatitis will not respond to antimicrobials, she is placed on Cephalexin (cephalexin) 250 mg IV q 8 hrs for cellulitis of the left arm and her risk of infection following surgery.

Anemia
She was also placed on oral iron supplementation Fer-in-sol 1.2 ml bid (ferrous sulfate) because her lab work revealed anemia as well.

First day post-op
After a good night’s sleep Anita was in much better spirits. Her foley catheter was removed and she had no problems getting out of bed and going to the bathroom. She was started on oral Tylenol (acetaminophen) after she tolerated her lunch well. Her IV and PCA were discontinued that evening and she was given oral antibiotics instead.

Second day post-op
Anita was progressing as expected and was discharged in the morning. Discharge teaching needs focused on

Please select the correct answer for each of the following questions. If you answer 80% or more correctly, you will be given the opportunity to register for continuing education credit. After receipt of the registration information and fee, a continuing education certificate will be mailed to you.

What information in the history is most important in the immediate care of this patient?

Swollen left arm
Anorexia and infrequent urination
Daughter of a single mother
Lack of varicella vaccine

Which of the following physical findings is least pertinent to the diagnosis and care of this patient?

Ascites
Multiple healing lesions
Mild, patchy lymphadenopathy
Dark amber colored urine

Question 3 What is the most significant lab value in assisting with the diagnosis of this patient?

Liver function tests, especially Aspartate Aminotransferase (AST)
CBC with differential
Bilirubin
Electrolytes

In interacting with this patient in a developmentally appropriate manner, the nurse should remember:

Erikson’s trust vs. mistrust stage
Never use restraints on a three-year-old
Three-year-olds behave better if their parents are not in the room during procedures.
Piaget’s Theory of Development

What is the highest priority nursing diagnosis for this patient upon arrival in the PIMCU after surgery?

Alteration in comfort related to patient’s complaints of severe abdominal pain and post-operative status
Fluid volume deficit related to decreased urinary output
Infection control related to chicken pox
Lack of knowledge related to vaccine for varicella

Good fluid intake during chicken pox illness
Post-exposure vaccination for chicken pox
Antibiotics
Varicella vaccine

Vaccination rates for chicken pox were 43.2 percent in 1998. What may be a contributing factor to this low rate?

Costs too much
Side effects
Perception that varicella is mild and vaccination is not warranted
Ineffectiveness of vaccine

	Patient Values	Normal Values
CBC WBC Bands Neutrophils Lymphocytes Platelets RBC Indices Hemoglobin Hematocrit MCV MCH MCHC	30,000 10% 30% 50% 180,000 per mm3 9.3 g/dL 29% 70 micrometers3 20 pg 25%	11,000-20,000 conventional units 3%-8% 54%-75% 25%-40% 150,000-450,000 per mm3 10.7-12.7/dL 32%-37.1% 81-99 micrometers3 27-31 pg 32%-36%
Erythrocyte sedimentation rate (ESR)	20	1-9 (Landau Method)
Electrolytes Sodium (Na+) Potassium (K+) Chloride (Cl-)	138 mEq/L 4.0 mEq/L 107 mEq/L	135-145 mEq/L 3.4-4.7 mEq/L 98-105 mEq/L
Liver Function tests Aspartate Aminotransferase (AST)** Alkaline phosphatase (ALP)	80 U/L 180 U/L	19-28 U/L 20-150 U/L
Albumin	1.8 g/dL	3.0-5.0 g/dL
Bilirubin - Total Direct Indirect	3.0 g/dL 1.4 g/dL 2.6 g/dL	0.3-1.2 g/dL 0.1-0.4 mg/dL 0.3-1.1 mg/dL
Urinalysis Color Appearance Odor Specific gravity PH Protein Glucose Ketones Blood Bilirubin Urobilinogen Nitrate Leukocyte esterase Microscopic Analysis RBCs WBCs Epithelial cells Casts Crystals	dark yellow, amber clear aromatic 1.050 6.8 negative negative positive negative positive positive negative negative 0 0 1-2 none few bilirubin crystals	pale yellow to amber clear to slightly cloudy mildly aromatic 1.001-1.035 4.5-8.0 negative negative negative negative negative 0.1-1.0 Ehrlich units/dL negative negative 0-3 per HPF 0-4 per HPF few occasional (hyaline or granular) occasional (uric acid, urate, phosphate, or calcium oxalate)