15.13 Infectious Mononucleosis/Epstein Barr

Infectious mononucleosis, commonly referred to as mono, is a viral infection generally caused by the Epstein-Barr virus (EBV). However, it can also be caused by cytomegalovirus, adenovirus, rubella, and other viruses. The focus of this section will be on infectious mononucleosis caused by the EBV. Typically, this condition is diagnosed in clients aged 15-24 years old. When very young children are infected with EBV, they are often asymptomatic.^[1]

Pathophysiology

EBV is spread person to person via contact with infected saliva; hence it is also known as the kissing disease. Once EBV is transmitted, it infects the cells of the salivary glands, mouth, and throat. The virus begins to replicate and spreads via the lymphatic system where it has an affinity for the B cells of the immune system. Although the person’s immune system will create antibodies against EBV, it is considered a lifelong disorder that can reactivate at a later date, particularly in those who are immunodeficient.^[2]

Assessment (Recognizing Cues)

Physical Exam

The most common presenting signs of infectious mononucleosis are an elevated temperature, sore throat, and enlarged cervical lymph nodes. See Figure 15.9^[3] for an image of a client with swollen lymph nodes due to infectious mononucleosis. The sore throat may also be accompanied by exudate on the tonsils, as well as petechiae on the roof of the mouth. Other signs and symptoms that may be seen are fatigue, headache, decreased intake, an enlarged spleen, and a generalized rash on the skin.^[4]

Potential complications of infectious mononucleosis include obstruction of the airway due to extremely enlarged lymph nodes, rupture of the spleen, anemia, and spread to the central nervous system. In most clients, the fatigue associated with infectious mononucleosis is prolonged and can last for months.^[5]

Common Laboratory and Diagnostic Tests

Infectious mononucleosis is typically diagnosed with a monospot test. The monospot test requires a sample of the client’s blood and provides results within ten minutes. However, false negatives can occur if testing is done early on in the course of illness, so it may need to be repeated at a later date. Blood can also be tested for antibodies to EBV, but results take much longer. A complete blood count is typically ordered, and results usually indicate increased white blood cells and potentially a decrease in platelets. If there is concern for spleen enlargement, imaging may also be performed.^[6],[7],[8]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with infectious mononucleosis include symptom management, monitoring for complications, and preventing spread of the disease.

Nursing diagnoses for clients with infectious mononucleosis are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Possible nursing diagnoses for clients with infectious mononucleosis are as follows^[9]:

• Hyperthermia r/t disease process
• Fatigue r/t disease process
• Imbalanced nutrition: less than body requirements r/t decreased oral intake
• Acute pain r/t disease process
• Risk for ineffective airway clearance r/t swelling of cervical lymph nodes

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, and realistic. These outcomes should be achievable within a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes include the following:

• The client will exhibit a temperature that is within normal limits for age within 48 hours.
• The client will display an increase in energy and engage in age-appropriate play within one week.
• The client will maintain their weight within a healthy range that is appropriate for their height throughout the course of the illness.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Treatment for infectious mononucleosis consists of supportive care. Acetaminophen and/or ibuprofen can be given to manage fever and sore throat. The client should also be encouraged to maintain adequate fluids and oral intake. Due to extreme fatigue, rest should also be promoted. If the spleen is enlarged, contact sports and other physical activities should be avoided for four to six weeks due to the risk of the spleen rupturing. In clients who have partial airway obstruction due to enlarged lymph nodes, steroids may be given to reduce inflammation.^[10]

Nursing Interventions

Registered nurses plan interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client.

When caring for a client with infectious mononucleosis, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching as discussed in the following subsections.^[11],[12]

Nursing Assessments

• Assess the client presenting with sore throat, fever, and enlarged cervical lymph nodes for a history of recent exposure to infectious mononucleosis.
• Assess the client’s vital signs to determine a baseline as they progress through medical treatment. Vitals may be altered if a complication, such as a splenic rupture or dehydration occurs.
• Assess the client’s fatigue on a scale of mild to severe to establish a baseline, as well as monitor for improvement.
• Assess the client’s nutritional intake, as poor nutrition may contribute to the client’s fatigue.

Nursing Actions

• Administer acetaminophen and ibuprofen for fever and pain per provider order.
• Administer steroid medications if airway compromise is present, per provider order.
• Elevate the head of the bed to encourage lung expansion and ease of breathing.
• Assist the client with progression of activity to increase their activity tolerance over time.
• Encourage oral hygiene to improve appetite during the course of the infection.

Client Teaching

• Educate the client and their parents/caregivers on the signs and symptoms of potential complications, especially rupture of the spleen. Signs of a splenic rupture include abdominal pain, shoulder pain, and decreased blood pressure.
• Teach clients to avoid sharing food, drinks, utensils, and personal care items such as toothbrushes to prevent the spread of infectious mononucleosis to others. Clients should also be advised to refrain from kissing others and to perform appropriate hand hygiene.
• Educate the client that EBV can remain in the saliva for up to 18 months.
• Educate the client on methods to conserve energy such as scheduling rest periods and prioritizing activities.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.