Mononucleosis, Infectious

Mononucleosis, Infectious

Causes

Genetic considerations

Gender, ethnic/racial, and life span considerations

Global health considerations

Assessment

History

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.

Physical examination

Common symptoms include fever, sore throat, and swollen 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. Use care during the examination and perform a gentle examination.

Psychosocial

The patient with IM has a viral illness that may last up to 4 weeks. Because most cases occur in college students, IM may prevent the student from performing academically at pre-illness 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.

Diagnostic highlights

Primary nursing diagnosis

Diagnosis

Outcomes

Interventions

Planning and implementation

Collaborative

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.

Pharmacologic highlights

No specific pharmacologic therapy treats mononucleosis; antiviral medications do not limit the EBV infection. Patients usually require analgesia with acetaminophen, propoxyphene (Darvon), or even oral narcotics. Some patients may also be placed on corticosteroids or antibiotics for complications such as inflammation, allergy, or infection.

Independent

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. Rest is critically important. Teach patients to avoid strenuous activities and contact sports until liver and spleen enlargement subsides.

Evidence-Based Practice and Health Policy

Macsween, K.F., Higgins, C.D., McAulay, K.A., Williams, H., Harrison, N., Swerdlow, A.J., & Crawford, D.H. (2010). Infectious mononucleosis in university students in the United Kingdom: Evaluation of the clinical features and consequences of the disease. Clinical Infectious Diseases, 50(5), 699–706.

• A study among university students, which included 57 cases of infectious mononucleosis and 58 age- and gender-matched control cases, revealed increased experiences of fatigue among women when compared to men (p = 0.003). Women reported a median fatigue duration of 194 days compared to men who reported a median of 80 days (p = 0.03).
• Sore throat was the most common presenting symptom (reported by 77% of patients), followed by fatigue (reported by 65% of patients) and lymphadenopathy (reported by 54% of patients and evident in 88% of patients upon physical examination). Seventeen percent of patients with infectious mononucleosis had splenomegaly, and 22% had hepatomegaly.
• Seventy-five percent of patients with infectious mononucleosis reported missing a median of 11 hours of scheduled classes (range, 0 to 300 hours); however, women were more likely than men to discontinue their studies (16% versus 0%; p = 0.056).

Documentation guidelines

• Physical findings of pharyngitis, lymphadenopathy, splenomegaly, fever, fatigue
• Reaction to activity and immobility
• Plan to deal with prolonged confinement and possible suspension of activities

Discharge and home healthcare 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.