replicates in epithelial cells of the pharynx and salivary glands. A localized inflammatory response produces the pharyngeal exudate. The virus is then carried via the lymphatics to the lymph nodes. Local and generalized lymphadenopathy (disease of the lymph nodes) develops. Major complications are rare but may include splenic or liver rupture, aseptic meningitis or encephalitis, pericarditis, or hemolytic anemia. EBV has been linked to Burkitt’s lymphoma, in Africa, and to nasopharyngeal carcinoma, particularly in Asians. Mononucleosis can also lead to Guillain-Barré syndrome.
Infection with EBV, a herpes virus, is common throughout the world in humans. EBV is probably spread via the oropharyngeal or respiratory route. EBV is also transmitted by blood transfusion.
The patient often reveals contact with a person who has had IM. Although children have a short incubation period of about 10 days, symptoms in adults may not appear until 1 to 2 months after exposure to the EBV. The patient with suspected IM typically reports a history of fever and fatigue for 1 week, followed by a sore throat (often described as the most painful the patient has ever experienced). Other symptoms include anorexia, painful swallowing, and swelling of the lymph nodes.
Note the redness of the pharynx and observe for exudate. Observe for petechiae that may appear at the junction of the hard and soft palates (occurs in 25% of patients). Note any facial edema, particularly eyelid edema. Facial edema is rarely encountered in other illnesses of young adults and is suggestive of IM. Some patients have a maculopapular rash (discolored patches of skin mixed with elevated red pimples). Palpate for enlarged lymph nodes in the cervical and epitrochlear (around the elbow) areas. Significant adenopathy is almost always present, and its absence should make one doubt the diagnosis of IM. During an abdominal examination, palpate for an enlarged spleen (occurring in 50% of patients) and liver.
The patient with IM has viral illness that may last up to 4 weeks. Since most cases occur in college students, IM may prevent the student from performing academically at preillness levels. If the student falls behind in her or his studies, the student or parents may feel anxious or stressed. Assess the patient’s ability to cope with the interference with school tasks. Determine if the patient has discussed the illness with her or his professors and if arrangements have been made to make up work or withdraw from school if needed. If the young adult is employed rather than in school, determine if the patient has told the employer of her or his healthcare needs.
Nursing care plan primary nursing diagnosis: Risk for ineffective airway clearance related or oropharyngeal swelling.
Nursing care plan intervention and treatment plan
Most patients require nothing more than supportive therapy, such as acetaminophen for fever and bedrest for fatigue. Pain relief is essential if the patient is to maintain fluid intake to prevent fluid volume deficit and dehydration. To prevent upper airway obstruction from severe tonsillar enlargement, treatment with corticosteroids (prednisone 40 mg/day for 5 to 7 days) is sometimes indicated. If the patient is at risk for airway obstruction (a rare complication), endotracheal intubation may be necessary. About 20% of patients also need a 10-day course of antibiotic therapy because of streptococcal pharyngotonsillitis. Ruptured spleen is an unusual but serious complication that causes sudden abdominal pain and is managed surgically by removal of the spleen.
Most patients do not require hospitalization for IM. Focus on supportive care and teaching. Encourage the patient to use anesthetic lozenges or warm saline gargles for pharyngitis. A soft diet such as milkshakes, sherbets, soups, and puddings provides additional liquid and nutritional supplements. Teach patients to avoid strenuous activities and contact sports until liver and spleen enlargement subsides.
Nursing care plan discharged and home health care guidelines
Teach the patient to prevent splenic rupture by avoiding minor trauma, heavy lifting, overexertion, and contact sports for 1 to 2 months. Teach strategies to avoid constipation and straining because these problems cause increased pressure on the spleen. Suggest over-the counter medications for comfort. Encourage the patient to rest during the acute illness and convalescence period. Note that prolonged fatigue is not uncommon. Encourage students to notify professors about the illness and to arrange for less-demanding assignments during the recovery period. Recommend that the patient plan for a recovery period of several weeks before resuming regular activities, academics, or employment. Instruct the patient to promptly report to the physician any abdominal and upper quadrant pain radiating to the shoulder. In addition, if the patient reports shortness of breath or inability to swallow, he or she should call 911 for emergency help because tracheostomy or intubation may become necessary.
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