N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide

Nursing assessment for mononucleosis: • Head to toe general assessment o Symptoms 

©2017 Achieve Test Prep Page 15 of 204 Inquire about time frame of symptoms; when they began and severity  Ask about behavior, such as sharing cups, utensils, toothbrushes, and kissing  Inquire about friends and relatives who may be infected or possibly exposed o Check airway patency if pharyngitis is present • Review laboratory and radiology reports o A CBC may be checked for lymphocytosis o MonoSpot is the most commonly ordered test since it detects heterophilic antibodies  High degree of false negatives or positives  Only effective during the acute phase of the illness o IgM: A test for anti-bodies to the Eppstein-Barr Virus; peaks in acute phase then declines o IgG: A test for anti-bodies to Eppstein-Barr; peaks after onset and stays detectable indefinitely o Ultrasound, CT Scan, and MRI: These tests can check for lymphadenopathy, including an enlarged spleen Nursing diagnosis for mononucleosis: • Activity intolerance related to fatigue and fever • Altered nutritional status related to throat pain and infectious process • Ineffective management of therapeutic regimen related to lack of knowledge of the disease Nursing interventions for mononucleosis: • Assess patients for symptoms, activity intolerance, nutritional status, and understanding of disease • Give supportive care for symptoms: o Encourage increased fluids o Instruct patient to use warm salt rinses o Analgesics/Antipyretics for pain and fever o Soft diet for throat pain • Encourage increased rest for activity intolerance o Provide a quiet place to rest o Encourage limiting activities, especially heavy lifting if spleen is involved during the acute phase o Help patient with ADLs if necessary