Immunizations and Health Screening: Practice Questions & Explanations

The 12-MONTH VISIT is one of the most vaccine-intensive well-child visits. The CDC Advisory Committee on Immunization Practices (ACIP) schedule typically includes at 12-15 months: MMR (Measles, Mumps, Rubella) — first dose; VARICELLA (chickenpox) — first dose; HEPATITIS A — first dose (series of 2 doses, 6 months apart); PCV15 or PCV20 (pneumococcal) — 4th dose; Hib (Haemophilus influenzae type b) — 4th dose (in some series); plus INFLUENZA annually starting at 6 months.

MMR caution: live attenuated vaccine — contraindicated in immunocompromised patients; delay if client recently received blood products or immunoglobulin; obtain pregnancy screen for any female of childbearing age (contraindicated in pregnancy); avoid pregnancy for 4 weeks after; may cause fever and mild rash 7-12 days post-injection.

Varicella: also live attenuated — same precautions as MMR. PN NURSING RESPONSIBILITIES at vaccine visits: review immunization record and identify needed vaccines; check for contraindications (fever, immunosuppression, pregnancy, prior severe reaction, egg allergy for some vaccines); provide VIS (Vaccine Information Statement) to parents before each vaccine; document vaccine, lot number, manufacturer, site, and route; monitor for immediate allergic reaction after injection; document in state immunization registry if required.

Important: PN/LVN scope typically includes administering vaccines and educating patients; development of the vaccine schedule and decisions about significant contraindications are RN/provider level decisions.

COLORECTAL CANCER SCREENING is recommended for all adults beginning at age 45 (the American Cancer Society updated their recommendation from 50 to 45 in 2018 due to rising rates in younger adults; the USPSTF now recommends starting at 45 as well). Earlier screening is recommended for HIGHER-RISK individuals: family history of colorectal cancer or polyps; personal history of polyps; inflammatory bowel disease (Crohn's disease, ulcerative colitis); Lynch syndrome or other hereditary conditions — these individuals may start at 40 or younger, depending on the specific risk.

Screening options: COLONOSCOPY every 10 years (gold standard — both diagnostic and therapeutic, can remove polyps during the same procedure); FECAL IMMUNOCHEMICAL TEST (FIT) or FECAL OCCULT BLOOD TEST (FOBT) — annually; STOOL DNA TEST (Cologuard) every 1-3 years; CT COLONOGRAPHY (virtual colonoscopy) every 5 years; FLEXIBLE SIGMOIDOSCOPY every 5 years.

Nursing role: provide education about colorectal cancer risk and the importance of screening; discuss available options; reinforce that colonoscopy prep (bowel preparation) is required and review instructions; remind that positive stool tests require follow-up colonoscopy. MAMMOGRAPHY is for breast cancer screening (annually or every 2 years starting at age 40-50 depending on risk and guidelines used). PSA is for prostate cancer screening in men (individualized decision starting at age 50-55).

Chest x-ray/ct: low-dose CT for lung cancer screening is recommended for high-risk adults (current or former heavy smokers ages 50-80).

SHINGLES (herpes zoster) is caused by reactivation of the varicella-zoster virus (VZV) — the same virus that causes chickenpox — which remains dormant in nerve tissue after initial infection. As people age, immunity wanes and VZV can reactivate, causing the painful shingles rash along a dermatome, and potentially postherpetic neuralgia (PHN) — severe, persistent pain lasting months or years. SHINGRIX (RZV — recombinant zoster vaccine): recommended for adults 50 and older; 2-DOSE SERIES, given 2-6 months apart; efficacy: >90% at preventing shingles and PHN; recommended even for: people who previously had shingles (can recur); people who received the older Zostavax vaccine; people who are unsure whether they've had chickenpox. ZOSTAVAX (live attenuated, ZVL): older vaccine; only 51% effective; no longer available in the US; people who received it should still get Shingrix.

Immunocompromised patients: Shingrix is a non-live vaccine; can be given to many immunocompromised adults but consult provider for specific conditions (guidelines have nuances for immunosuppressed patients). COMMON SIDE EFFECTS of Shingrix: injection site reactions (soreness, redness, swelling), systemic reactions (myalgia, fatigue, headache, fever) — often quite significant and last 2-3 days; clients should be warned so they don't mistake side effects for illness; recommend scheduling injection before a rest day.

Nursing role: assess immunization history; provide Shingrix per schedule; educate on side effects and expected response; document administration.

HUMAN PAPILLOMAVIRUS (HPV) is the most common sexually transmitted infection in the US. Certain HPV strains cause: cervical cancer, vaginal and vulvar cancer, anal cancer, oropharyngeal cancer, penile cancer, and genital warts. HPV VACCINE (Gardasil 9): protects against 9 HPV strains (including types 16 and 18, which cause about 70% of cervical cancers, and types 6 and 11, which cause about 90% of genital warts).

Recommended schedule: PRETEENS (11-12 years): best timing — before any sexual exposure; 2-DOSE series if started before age 15 (0 and 6-12 months apart); 3-DOSE series if starting at age 15 or older, or if immunocompromised.

Catch-up: recommended through age 26 for those not vaccinated; shared clinical decision-making for adults 27-45 (less benefit at older ages due to prior exposure).

Males and females: both benefit — prevents cancers in males too (anal, penile, oropharyngeal) and reduces transmission.

PAP smears: the HPV vaccine does NOT eliminate the need for cervical cancer screening (Pap smear/cervical cytology) — the vaccine doesn't protect against 100% of cancer-causing HPV strains; screening continues as recommended (starting at age 21 for most women, Pap every 3 years, or Pap + HPV co-test every 5 years starting at 30).

Safety: the HPV vaccine is one of the most studied vaccines; common side effects are injection site reactions and brief fainting (syncope is relatively common with this vaccine — observe for 15 minutes post-injection).

Pn education: address common misconceptions (it does NOT encourage sexual activity, it does NOT affect fertility); emphasize recommended age; document vaccine administration and counsel on side effects.

PNEUMOCOCCAL VACCINATION protects against Streptococcus pneumoniae, which causes pneumonia, meningitis, and bacteremia — conditions with high mortality especially in elderly and immunocompromised individuals. CURRENT CDC RECOMMENDATIONS (as of most recent guidelines): Adults 65 and older: pneumococcal vaccination recommended for all; Adults 19-64 with HIGH-RISK CONDITIONS: Immunocompromising conditions (HIV, transplant, cancer treatment, asplenia); Chronic conditions: heart disease, lung disease, liver disease, kidney disease, diabetes mellitus, CSF leaks, cochlear implants; Cigarette smoking (increases pneumococcal pneumonia risk).

Vaccine formulations: PCV15 (Prevnar 15) and PCV20 (Prevnar 20) are CONJUGATE vaccines — provide better immune memory; PPSV23 (Pneumovax 23) is a POLYSACCHARIDE vaccine — recommended as additional coverage after conjugate vaccine in some high-risk patients.

Schedule complexity: The schedule depends on prior vaccination history; for naive adults 65+, current guidelines generally recommend PCV20 alone OR PCV15 followed by PPSV23 — consult current CDC schedule.

Pn role: Assess vaccination history; administer per schedule; document; educate client that protection is not immediate (takes ~2 weeks); common side effects include injection site soreness, mild fever.

Colorectal cancer screening: In 2021, the USPSTF lowered the recommended starting age from 50 to 45 years for average-risk adults, in response to rising colorectal cancer rates in the 45-54 age group. SCREENING OPTIONS at 45: Colonoscopy every 10 years (gold standard — can both detect and remove polyps); Annual high-sensitivity fecal occult blood test (FOBT) or fecal immunochemical test (FIT); Stool DNA test every 1-3 years; CT colonography every 5 years. HIGH-RISK GROUPS start earlier: family history of colorectal cancer or polyps — may start at 40 or 10 years before the age of diagnosis in the family member; inflammatory bowel disease — may start 8-15 years after IBD onset; Lynch syndrome — colonoscopy starting at 20-25; hereditary polyposis syndromes — flexible sigmoidoscopy starting in late teen years.

Annual influenza vaccination: Recommended for: EVERYONE 6 months and older, annually; SPECIAL PRIORITY GROUPS (higher risk of severe flu): Adults 65+; Pregnant women; People with chronic conditions (heart disease, diabetes, asthma, kidney disease, immunocompromise); Healthcare workers (to protect themselves and patients).

Why annual: Influenza virus mutates rapidly; each year's vaccine is updated to match predicted circulating strains; immunity from prior year's vaccine declines; the vaccine is reformulated annually.

Timing: Ideally September-October before flu season peaks (usually December-February); but vaccine any time during flu season is better than none.

Contraindications: Previous severe allergic reaction to the vaccine or any of its components. Egg allergy: most people with egg allergy can receive most flu vaccines; consult an allergist for history of anaphylaxis to egg.

Acc/aha 2017 blood pressure categories: Normal: <120/<80; Elevated: 120-129/<80; Stage 1 HTN: 130-139 OR 80-89; Stage 2 HTN: ≥140 OR ≥90; Hypertensive Crisis: >180/>120. 138/88 = Stage 1 hypertension (systolic 130-139, diastolic 80-89).

Nursing implications: Report to RN/provider; reinforce lifestyle modifications (DASH diet, sodium restriction <2.3g/day, 150 min/week moderate exercise, weight loss, smoking cessation, alcohol moderation); medication may be initiated depending on cardiovascular risk; repeat measurements to confirm; document. Stage 1 HTN with low cardiovascular risk may be managed with lifestyle changes alone initially.