A 6-year-old child is admitted to the pediatric unit with suspected diphtheria. The child presents with a characteristic grayish-white membrane covering the throat and difficulty swallowing. Which nursing intervention should be the highest priority?
1Administer prescribed antibiotics immediately
2Encourage oral fluid intake to prevent dehydration
3Provide comfort measures and pain management
4Prepare for emergency airway management and have tracheostomy equipment readily available✓ 정답
해설
Emergency airway management is the highest priority due to the risk of complete airway obstruction from the diphtheria pseudomembrane. Other interventions like antibiotics are secondary until the airway is secured.
Core Nursing Explanation
This question tests the nurse's ability to prioritize care for a pediatric patient with a life-threatening infectious disease. The core concept is Airway, Breathing, Circulation (ABC) Priority. In any clinical scenario, securing the airway is always the highest priority if it is compromised or at imminent risk.
Key Concept Analysis
The question describes a child with suspected Diphtheria, a serious bacterial infection caused by Corynebacterium diphtheriae. The key pathophysiological threat is the formation of a thick, leathery Pseudomembrane in the throat (pharynx, tonsils, uvula). This membrane is composed of dead tissue, bacteria, and inflammatory cells and can detach or enlarge, causing sudden, complete airway obstruction. The symptoms "grayish-white membrane" and "difficulty swallowing" are classic signs of this impending airway emergency.
Answer RationaleKey Point! The highest priority nursing intervention is to Prepare for emergency airway management. The membrane can occlude the airway without warning, leading to respiratory arrest. Having Tracheostomy equipment ready is critical because if the obstruction occurs above the level of the vocal cords, endotracheal intubation may be impossible. A tracheostomy creates a surgical airway below the obstruction. This aligns perfectly with the ABC framework—Airway is the absolute first priority.
Distractor AnalysisWatch out for confusion! While all other options are part of diphtheria management, they are not the immediate priority when the airway is at risk.
① Administer prescribed antibiotics (e.g., penicillin or erythromycin) is essential to kill the bacteria and stop toxin production, but it does not dissolve the existing membrane or immediately secure the airway. This is a secondary priority.
② Encourage oral fluid intake is potentially dangerous. With difficulty swallowing and a compromised airway, forcing oral fluids increases the risk of Aspiration. Hydration, if needed, should be provided intravenously (IV).
③ Provide comfort measures is important for patient-centered care but does not address the imminent threat to life. Pain management and emotional support are implemented after stabilizing the airway.
Related Concepts
Nursing care for diphtheria also includes strict Contact and droplet isolation (until antibiotics have been administered for 24 hours and cultures are negative), administration of Diphtheria antitoxin to neutralize circulating toxin, and close monitoring for complications like Myocarditis (heart muscle inflammation) and Neuritis (nerve inflammation).
Concept Summary
Concept
Key Takeaway
Pathophysiology of Diphtheria
Toxin-producing bacteria cause a pseudomembrane that can obstruct the airway.
Nursing Priority (ABCs)
Airway management is always the highest priority in potential obstruction.
Isolation Precautions
Strict contact and droplet precautions are required.
Secondary Interventions
Antibiotics, antitoxin, IV fluids, and cardiac monitoring follow airway security.
Prepare for emergency surgical airway (tracheostomy).
Epiglottitis (Haemophilus influenzae type b)
Rapid swelling of the epiglottis supraglottic structure.
Do NOT examine throat. Keep child calm, prepare for controlled intubation in OR.
Croup (Laryngotracheobronchitis)
Subglottic edema causing inspiratory stridor and barking cough.
Provide cool mist humidity, administer corticosteroids/racemic epinephrine.
Anatomy, Physiology & Pharmacology Points
Anatomy: The pseudomembrane typically forms in the Oropharynx and Nasopharynx. Airway obstruction can occur at the level of the pharynx or larynx.
Pathophysiology: The bacterial exotoxin causes local tissue necrosis (forming the membrane) and can be absorbed into the bloodstream, damaging distant organs, particularly the heart and nerves.
Pharmacology:Diphtheria Antitoxin is given to neutralize unbound toxin. It must be administered early, as it only works on circulating toxin, not toxin already bound to cells.
Memory Tips
ABCs for D: For Diphtheria, remember Airway first, Bacteria (antibiotics) second, Cardiac (monitor for myocarditis) third.
Membrane = Menace: The gray membrane is a direct menace to the airway. Think "Membrane = Manage Airway."
High-Frequency NCLEX Topics
The NCLEX frequently tests prioritization using the ABC framework. Pediatric airway emergencies (like diphtheria, epiglottitis, foreign body aspiration) are classic high-yield scenarios. Be prepared to choose the intervention that directly addresses an immediate threat to airway patency over other correct but less urgent actions.
Watch Out for Question Variations!
Shift to Isolation: "What type of isolation precautions should the nurse initiate for a child with diphtheria?" (Answer: Contact and Droplet precautions).
Shift to Medication: "The nurse is preparing to administer diphtheria antitoxin. What is the nurse's priority action before administration?" (Answer: Check for horse serum allergy via skin test, as antitoxin is derived from horses).
Shift to Complication: "A client recovering from diphtheria reports palpitations and weakness. Which complication should the nurse suspect?" (Answer: Myocarditis).
Nursing Clinical Practice GuideClinical Scenario
You are the nurse on a pediatric unit. A 6-year-old is brought in by parents who report a sore throat, fever, and a "barking" cough that started two days ago. On assessment, you note stridor (high-pitched sound on inspiration), drooling, and the child prefers to sit up and lean forward (tripod position). You visualize a grayish membrane at the back of the throat. The child appears anxious and is struggling to breathe.
Nursing Intervention Strategy
1. Immediate Action (Priority): Do NOT leave the child alone. Call a rapid response or code for airway emergency. Alert the physician and respiratory therapist immediately. Do not attempt to visualize the throat further or obtain a throat culture, as this can trigger laryngospasm and complete obstruction.
2. Prepare for Airway Management: Ensure the emergency cart and Tracheostomy tray are at the bedside. The team will likely prepare for an emergency tracheostomy or cricothyrotomy.
3. Supportive Care: Keep the child as calm as possible. Provide 100% oxygen via non-rebreather mask if tolerated. Start IV access for emergency medications and fluids.
4. Infection Control: Once the airway is secure, place the child in a private room and initiate Contact and Droplet Precautions. Don appropriate PPE (gown, gloves, mask).
5. Post-Stabilization Care: Administer prescribed antibiotics and diphtheria antitoxin. Monitor closely in an ICU setting for respiratory status and signs of myocarditis (e.g., tachycardia, hypotension, ECG changes).
Patient Safety and Precautions
Never Force Oral Intake: With dysphagia and airway compromise, NPO (nothing by mouth) status is maintained until the airway is definitively secure and swallowing is reassessed.
Isolation Compliance: Strictly adhere to isolation protocols. All staff and visitors must use PPE. The disease is highly contagious through respiratory droplets and contact with lesions.
Antitoxin Administration: The diphtheria antitoxin is derived from horse serum. A skin test for sensitivity must be performed prior to administration to prevent anaphylaxis.
Nursing Procedure & Medication FlowEmergency Tracheostomy Preparation:
1. Gather sterile tracheostomy tray, suction equipment, and appropriate-sized tracheostomy tubes.
2. Assist physician with positioning (neck hyperextended).
3. Anticipate need for suctioning during the procedure.
4. After placement, secure the tube, auscultate for bilateral breath sounds, and connect to humidified oxygen/ventilator.
Medication Administration:
1. Antibiotics (Penicillin G/Erythromycin): Given IV to achieve rapid bactericidal levels. Monitor for allergic reactions.
2. Diphtheria Antitoxin: Administered IV after a negative skin test. Given in a monitored setting due to risk of anaphylaxis or serum sickness.
A Word from Your Senior Nurse
"In pediatrics, a quiet child with respiratory distress is often in more trouble than a crying one. The anxiety and tripod positioning in this scenario are huge red flags. Your number one job is to be the advocate who recognizes the silent emergency—the airway that's about to close. On the NCLEX and in real life, when you see 'diphtheria' and 'membrane,' your brain should instantly scream 'AIRWAY!' Mastering this kind of prioritization thinking is what separates a good test-taker from a great nurse."
Diphtheria — A serious bacterial infection caused by Corynebacterium diphtheriae, characterized by the formation of a pseudomembrane in the throat that can lead to life-threatening airway obstruction and systemic complications like myocarditis.
Pseudomembrane — A thick, grayish-white, adherent membrane composed of dead tissue, fibrin, inflammatory cells, and bacteria that forms on mucous membranes, particularly in the throat, in diseases like diphtheria. It is a key diagnostic sign and the source of airway obstruction.
Tracheostomy — A surgical procedure to create an opening (stoma) through the neck into the trachea to establish an airway. It is a critical emergency intervention for upper airway obstructions, as in severe diphtheria, when endotracheal intubation is not possible.
ABC Priority (Airway, Breathing, Circulation) — The fundamental framework for prioritizing patient care and interventions. Securing and maintaining a patent airway is always the first and highest priority in any clinical assessment or emergency situation.
Contact and Droplet Precautions — Infection control measures used for pathogens spread by close contact with the patient or their environment and by large respiratory droplets. For diphtheria, this involves wearing a gown, gloves, and a mask when within 3 feet of the patient and using dedicated patient-care equipment.