Infectious And Anemia PDF

**Endocarditis** - inflammation of the endothelial surface of the heart - can be either infective (caused by microorganisms such as bacteria and fungi) or non-infective (autoimmune disorders) - Infective: staphylococci or streptococci - Ports of entry for the infecting organism inclu...

**Endocarditis** - inflammation of the endothelial surface of the heart - can be either infective (caused by microorganisms such as bacteria and fungi) or non-infective (autoimmune disorders) - Infective: staphylococci or streptococci - Ports of entry for the infecting organism include the oral cavity (especially if the client has had a dental procedure in the previous 3 to 6 months), infections (cutaneous, genitourinary, gastrointestinal, and systemic), and surgery or invasive procedures, including IV line placement. - **Risk factors:** - Presence of prosthetic heart valves and cardiac devices (e.g., pacemaker) - Presence of structural cardiac defects - Older adults - IV drug abuse - Hospital acquired (hemodialysis or prolonged IV fluid or antibiotic therapy) - Immunosuppressive medications - Body piercing (especially oral, nasal, and nipple), branding, and tattooing Deformity or injury of the endocardium Accumulation of fibrin and platelets (clot formation) on the endocardium Infectious organisms invade the clot and endocardial lesion Vegetation of microorganism Vegetations may embolize to other tissues throughout the body (systemic emboli) Infection may erode through the endocardium into underlying structures Tears or other deformities of valve leaflets, dehiscence of prosthetic valves, deformity of chordae tendineae, or mural abscesses - **Clinical Manifestations** - Fever (intermittent or absent) - Heart murmur - Clusters of petechiae may be found on the body - **Osler nodes** - small, painful nodules on pads of fingers or toes - **Janeway lesions** - irregular, red or purple, painless flat macules on palms, fingers, hands, soles, and toes - **Roth spots** - hemorrhages with pale centers in fundi of the eyes - **Splinter hemorrhages** - under the proximal half of fingernails and toenails. - Petechiae may appear in conjunctiva and mucous membranes - Malaise - Anorexia - Weight loss - Back and joint pain - Cardiomegaly - Heart failure - Tachycardia - Splenomegaly - Headache - Temporary or transient cerebral ischemia (stroke) - **Diagnostic Findings** - 2 sets of blood cultures -- definitive diagnosis, before administration of any antimicrobial agents - Elevated white blood cell (WBC) counts - Positive rheumatoid factor - Elevated ESR - Echocardiography - **Prevention** - Antibiotic prophylaxis - for high-risk patients immediately before and sometimes after dental procedures - Good oral hygiene - Avoid using toothpicks or other sharp objects in the oral cavity - Avoid nail biting - Avoid body piercing, branding, tattooing - Minimize outbreaks of acne, psoriasis - Addiction treatment programs - Avoid IUD - Meticulous hand hygiene, site preparation, and aseptic technique during insertion and maintenance procedures - All catheters, tubes, drains, and other devices are removed as soon as they are no longer needed or no longer function - **Medical and Surgical Management** - Antibiotic therapy - 2 to 6 weeks every 4 hours or continuously by IV infusion - Penicillin -- DOC for bacterials - Amphotericin B-- DOC for fungal - Surgery -- if nonresponsive to medications - Valve debridement or excision - Debridement of vegetations - Debridement and closure of an abscess - Closure of a fistula - Aortic or mitral valve debridement, excision, or replacement - **Nursing Management** - Assess heart sounds - new or worsening murmur may indicate complications - Administer antibiotic, antifungal, or antiviral medication as prescribed - Adherence or medication compliance - Increase OFI - Balance rest and activities -- rest periods due to fatigue - Good infection control and prevention practices - Administer NSAIDs or antipyretics as prescribed - Maintain antiembolism stockingsifprescribed. - Manage fever with cooling techniques such as with a fan, tepid water baths, or cloth compresses - if\ shivering or piloerection occurs, these interventions should be discontinued due to increased oxygen consumption and potential to further increase of body temperature - Monitor for signs and symptoms of systemic embolization - **Splenic emboli** - as evidenced by sudden abdominal pain radiating to the left shoulder and the presence of rebound abdominal tenderness on palpation - **Renal emboli** - as evidenced by flank pain radiating to the groin, hematuria, and pyuria. - **Central nervous system emboli** - confusion, aphasia, or dysphasia - **Pulmonary emboli** - as evidenced by pleuritic chest pain, dyspnea, and cough - All invasive lines and wounds must be assessed daily for redness, tenderness, warmth, swelling, drainage, or other signs of infection **Myocarditis** - inflammatory process involving the myocardium, can cause heart dilation, thrombi on the heart wall (mural thrombi), infiltration of circulating blood cells around the coronary vessels and between the muscle fibers, and degeneration of the muscle fibers themselves - caused by: - Infection (viral, bacterial, rickettsial, fungal, parasitic, metazoal or protozoal, spirochetal) - Immune related (immunosuppression therapy) - Inflammatory reaction to toxins (ethanol, radiation therapy) - **Clinical Manifestations** - May be asymptomatic, with an infection that resolves on its own - Fatigue and dyspnea - Tachycardia - Syncope - Palpitations - Discomfort in the chest and upper abdomen - Flulike symptoms (most common) - Pericardial friction rub - Gallop rhythm - Murmur that sounds like fluid passing an obstruction - Pulsus alternans - Complications: sudden cardiac death and severe CHF - **Diagnostic Findings** - MRI with contrast - CBC -- increased WBC - ECG - dysrhythmias or ST--T-wave changes - Increase ESR or CRP - **Prevention** - Appropriate immunizations (e.g., influenza, hepatitis) - Early treatment - **Medical Management** - Bed rest to decrease cardiac workload - Activities, especially athletics, should be limited for a 6-month period or at least until heart size and function have returned to normal - Physical activity is increased slowly, and the patient is instructed to report any symptoms that occur with increasing activity, such as a rapidly beating heart - Antibiotics as prescribed (penicillin for hemolytic streptococci) - NSAIDs should not be used for pain control - ineffective in relieving the inflammatory process in myocarditis and have\ been linked to worsening inflammation of the myocardium. This also can contribute to an increased mortality from increased virulence of the pathogen - **Nursing Management** - Assess for signs and symptoms of heart failure and dysrhythmias - Continuous cardiac monitoring with personnel and equipment readily available to treat life-threatening dysrhythmias - Assist the client to a position of comfort, such as sitting up and leaning forward. - Administer oxygen as prescribed - Patients with myocarditis are sensitive to digitalis -- monitor for toxicity (WOF new onset of dysrhythmia, anorexia, nausea, vomiting, headache, and malaise) - Anti-embolism stockings - Passive and active exercises **Pericarditis** - inflammation of the pericardium, which is the membranous sac enveloping the heart - may be acute, chronic, or recurring - may occur 10 days to 2 months after acute myocardial infarction - may be a primary illness, or it may develop during various medical and surgical disorders - Classifications: - **Adhesive (constrictive)** - the layers of the pericardium become attached to each other and restrict ventricular filling - **Serous** -- accumulation of serum in the pericardial sac - **Purulent** - accumulation of pus in the pericardial sac - **Calcific** - accumulation of calcium deposits in the pericardial sac - **Fibrinous** - accumulation of clotting proteins in the pericardial sac - **Sanguinous** - accumulation of blood in the pericardial sac - **Malignant** -- cancer - **Causes:** - Idiopathic or nonspecific causes - Infection: usually viral, rarely bacterial, fungal or parasitic - Disorders of connective tissue -- SLE, RA, rheumatic fever - Sarcoidosis - Hypersensitivity states: immune reactions, medication reactions, and serum sickness - Disorders of adjacent structures: myocardial infarction, dissecting aneurysm, pleural and pulmonary disease (pneumonia) - Neoplastic disease -- due to metastasis - Radiation therapy of chest and upper torso (peak occurrence 5--9 months after treatment) - Trauma: chest injury, cardiac surgery, cardiac catheterization, implantation of pacemaker, or implantable cardioverter defibrillator Inflammation of the pericardium Accumulation of fluid in the pericardial sac **(pericardial effusion)** Increased pressure on the heart **(cardiac tamponade)** Frequent or prolonged episodes of pericarditis Thickening and decreased elasticity of the pericardium Fusion of the visceral and parietal pericardium Ventricular expansion during ventricular filling is restricted **(constrictive pericarditis)** Decreased cardiac output (heart failure) Increased systemic venous pressure Systemic congestion and hepatic failure - **Clinical Manifestations** - May be asymptomatic - Chest pain - may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region - remains fairly constant, but it may worsen with deep inspiration and when lying down or turning - pain is grating and is aggravated by breathing (particularly inspiration), coughing, and swallowing - Pain is worse when in the supine position and may be relieved by leaning forward - Creaky or scratchy friction rub heard most clearly at the left lower sternal border at the end of exhalation (pericardial friction rub) - place the diaphragm of the stethoscope tightly against the patient's thorax - auscultate the left sternal edge in the fourth intercostal space - heard best when a patient is sitting - to differentiate pericardial friction rub from a pleural friction rub, the patient is asked to hold their breath; a pericardial friction rub will continue to be heard - Mild fever - Fatigue and malaise - Nonproductive cough or hiccup - Dyspnea - Respiratory splinting -- because of pain upon inspiration - Elevated white blood cell count - **Diagnostic Findings** - Echocardiogram - may detect inflammation, pericardial effusion or tamponade, and heart failure - TEE - CT imaging - best diagnostic tool for determining size, shape, and location of pericardial effusions - Cardiac MRI may assist with detection of inflammation and adhesions - Video-assisted pericardioscope-guided biopsy of the pericardium or epicardium - to obtain tissue samples for culture and microscopic examination - 12-lead ECG - ST elevations. depressed PR segments or atrial dysrhythmias - **Medical Management** - Analgesic medications and NSAIDs - pain relief during the acute phase. Indomethacin (Indocin) is contraindicated because it may decrease coronary blood flow. - Colchicine (Colcrys) or corticosteroids (e.g., prednisone) - if the pericarditis is severe or if the patient does not respond to NSAIDs - Pericardiocentesis - Pericardial window - a small opening made in the pericardium to allow continuous drainage into the chest cavity - Pericardiectomy - Surgical removal of tough encasing pericardium to release both ventricles from constrictive and restrictive inflammation and scarring - **Nursing Management** - Administer analgesics as prescribed - Administer oxygen. - Educate and reassure patient that the pain is not due to a heart attack - Forward-leaning or sitting position -- to relieve pain and discomfort - Activity restrictions until pain and fever subside - Encourage gradual increase of activity as condition improves - Be alert to cardiac tamponade **Hematologic Function** **Anatomic and Physiologic Overview** **Blood** - Connective tissue - 7% to 10% of the normal body weight - Amounts to 5 to 6 L of volume - Functions: - Carries oxygen and nutrients to the body cells for cellular metabolism - Carries hormones, antibodies, and other substances - Carries waste products produced by cellular metabolism to the lungs, skin, liver, and kidneys, where they are transformed and eliminated from the body - Prevents bleeding - Three primary cell types - 40% to 45% of the blood volume - **Erythrocytes (RBC) --** carries hemoglobin to provide oxygen to the tissues. It has an average lifespan of 120 days - **Leukocytes (WBC) --** fights infection - **Neutrophil --** prevents or limits bacterial infection via phagocytosis - **Monocyte --** enters tissue as macrophage; highly phagocytic especially fungus; immune surveillance - **Eosinophil --** allergic reactions (neutralizes histamine); digests foreign particles; phagocytosis of parasites - **Basophil --** contains histamine; integral part of hypersensitivity reactions - **T Lymphocyte --** cell mediated immunity, example: delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells - **B lymphocyte --** humoral immunity, example: production of immunoglobulins - **Thrombocytes (Platelets) --** fragment of megakaryocyte; coagulation; hemostasis; average lifespan of 10 days - **Hematopoiesis --** process of blood cell formation. - Primary site is the bone marrow though the liver and spleen may also be involved during embryonic development and in other conditions (extramedullary hematopoiesis) - Under normal conditions, the adult bone marrow produces about 175 billion erythrocytes, 70 billion neutrophils (a mature type of WBC), and 175 billion platelets each day. - Limited to the pelvis, ribs, vertebrae, and sternum - **Stem cells -** primitive cells of the bone marrow, have the ability to self-replicate, thereby ensuring a continuous supply of stem cells throughout the life cycle - When stimulated to do so, stem cells can begin a process of **differentiation** into either **myeloid** or **lymphoid** stem cells - **Lymphoid stem cells -** produce either T or B **lymphocytes** - **Myeloid stem cells** - differentiate into three broad cell types: erythrocytes, leukocytes, and platelets - **Erythrocytes (Red Blood Cells)** - biconcave disc that resembles a soft ball compressed between two fingers - has a diameter of about 8 mcm and is so flexible that it can pass easily through capillaries that may be as small as 2.8 mcm in diameter - membrane of the red cell is very thin so that gases, such as oxygen and carbon dioxide, can easily diffuse\ across it - have no nuclei and they have many fewer metabolic enzymes than do most other cells - the disc shape provides a large surface area that facilitates the absorption and release of oxygen molecules - consist primarily of **hemoglobin**, which contains iron and makes up 95% of the cell mass - Hemoglobin - made up of four subunits (heme portion attached to a globin chain) - Iron is present in the heme component of the molecule - Heme has the ability to bind to oxygen loosely and reversibly - **[FUNCTION: transport of oxygen between the lungs and tissues ]** - **Reticulocytes** - slightly immature forms of erythrocytes - **Erythropoiesis -** erythrocyte production, entire process takes less than 5 days - **Erythropoietin -** hormone produced primarily by the kidney to stimulate the bone marrow to produce RBC - For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors - **Red Blood Cell Destruction** - average lifespan of a normal circulating erythrocyte is 120 days - aged erythrocytes lose their elasticity and become trapped in small blood vessels and the spleen - they are removed from the blood by the reticuloendothelial cells, particularly in the liver and the spleen - as the erythrocytes are destroyed, most of their hemoglobin is recycled - some hemoglobin also breaks down to form bilirubin and is secreted in the bile - **Iron Stores and Metabolism** - Iron is normally absorbed from the small intestine - Additional amounts of iron, up to 2 mg daily, must be absorbed by women of childbearing age to replace that lost during menstruation - Total body iron content in the average adult is approximately 3 g - Iron is stored as ferritin and when required, the iron is released into the plasma, binds to transferrin, and is transported into the membranes of the normoblasts (erythrocyte precursor cells) within the marrow, where it is incorporated into hemoglobin - Iron is lost in the feces, either in bile, blood, or mucosal cells from the intestine - Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow) - Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults - The source of iron deficiency should be investigated promptly, because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer - **Vitamin B12 and Folate Metabolism** - Vitamin B12 and folate are required for the synthesis of deoxyribonucleic acid (DNA) in RBCs - Both vitamin B12 and folate are derived from the diet - Folate is absorbed in the proximal small intestine, but only small amounts are stored within the body - Vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12 - Vitamin B12 combines with intrinsic factor produced in the stomach - absorbed in the distal ileum - **Leukocytes (White Blood Cells)** - two general categories: granulocytes and lymphocytes - total leukocyte count is 4000 to 11,000 cells/mm3 - approximately 60% to 80% are granulocytes and 20% to 40% are lymphocytes - **Granulocytes -** defined by the presence of granules in the cytoplasm of the cell - Eosinophils - Basophils - Neutrophils - **Agranulocytes** - Monocytes - largest of the leukocytes - Lymphocytes - **[FUNCTION: protect the body from invasion by bacteria and other foreign entities]** - **Platelets (Thrombocytes)** - not technically cells; rather, they are granular fragments of giant cells in the bone marrow called ***megakaryocytes*** - **[FUNCTION: essential role in the control of bleeding]** - Platelets have a normal lifespan of 7 to 10 days - **Plasma and Plasma Proteins** - Liquid portion of the blood - More than 90% of plasma is water; remainder consists primarily of plasma proteins; clotting factors (particularly fibrinogen); and small amounts of other substances, such as nutrients, enzymes, waste products, and gases - Plasma proteins consist primarily of albumin and globulins. **Bone Marrow Aspiration and Biopsy** - Performed when additional information is needed to assess how a patient's blood cells are being formed and to assess the quantity and quality of each type of cell produced within the marrow - These tests are also used to document infection or tumor within the marrow - Normal bone marrow is in a semifluid state and can be aspirated through a special large needle - **[SITES: iliac crest and occasionally from the sternum]** - **Nursing Management** - Informed consent - Skin prep using aseptic technique - Done under local anesthesia - Explain sensation: - Patients typically feel a pressure sensation as the needle is advanced into position - Actual aspiration always causes sharp but brief pain - DBE and relaxation techniques often helps ease the discomfort - Assist the patient in maintaining a comfortable position and encourage relaxation and deep breathing throughout the procedure - Complications: bleeding and infection - Apply pressure to the site for several minutes and cover with a sterile dressing - Warm tub baths and a mild analgesic agent as prescribed - Aspirin-containing analgesic agents should be avoided in the immediate post-procedure period because they can aggravate or potentiate bleeding **ANEMIA** - condition in which the hemoglobin concentration is lower than normal - amount of oxygen delivered to body tissues is diminished - most common hematologic condition - Classifications: - **Hypoproliferative** - bone marrow does not produce adequate numbers of erythrocytes - **Hemolytic** - premature destruction of erythrocytes results in the liberation of hemoglobin from the erythrocytes into the plasma; released hemoglobin is converted in large part to bilirubin and, therefore, the **[bilirubin concentration rises]** - **Bleeding** -- resulting from RBC loss A. **Iron Deficiency Anemia** - Most common type of anemia in all age groups, and it is the most common anemia in the world - **Causes** - Intake of dietary iron is inadequate for hemoglobin synthesis - Blood loss - bleeding from ulcers, gastritis, inflammatory bowel disease, or GI tumors (most common cause of IDA among men and postmenopausal women) - Menorrhagia (excessive menstrual bleeding) and pregnancy with inadequate iron supplementation (most common cause of IDA among premenopausal women) - Chronic alcoholism - Prolonged use of medications such as aspirin, steroids, or nonsteroidal anti-inflammatory drugs (NSAIDs) - Iron malabsorption - gastrectomy, bariatric surgery, or with celiac or other inflammatory bowel disease - **Clinical Manifestations** - Smooth, red tongue - Tachycardia - Fatigue - Brittle and ridged nails - Angular cheilosis - **Diagnostic Findings** - Bone marrow aspiration - definitive method of establishing the diagnosis - MCV - measures the size of the erythrocytes, decreased in IDA - Decrease hematocrit and RBC levels - Decreased hemoglobin level - **Medical Management** - **Oral iron supplementation** -- ferrous sulfate, ferrous gluconate, and ferrous fumarate - Taken on an empty stomach - an hour before meals - GI side effects (primarily constipation, but also cramping, nausea, and vomiting) - Taking iron with vitamin C increases absorption of the iron - Iron absorption is reduced with food, especially dairy products. - Eat foods high in fiber to minimize problems with constipation - Remember that stools will become dark in color - Prevent staining the teeth with a liquid preparation by using a straw or placing a spoon at the back of the mouth to take the supplement. Rinse the mouth thoroughly afterward. - **Parenteral Iron Formulations** - **Nursing Management** - Preventive education - Food sources high in iron - taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron - Organ meats (e.g., beef or calf's liver, chicken liver) - Meats - Beans (e.g., black, pinto, and garbanzo) - Leafy green vegetables - Raisins - Molasses - Balance rest and activity B. **Aplastic Anemia** - Rare disease caused by a decrease in or damage to marrow stem cells, damage to the microenvironment within the marrow, and replacement of the marrow with fat - Stem cell damage is caused by the body's T cells mediating an inappropriate attack against the bone marrow, resulting in bone marrow **aplasia** (i.e., markedly reduced hematopoiesis) - Significant neutropenia and thrombocytopenia also occur - **Causes:** - Idiopathic - Viral infections - Medications, chemicals, or radiation damage - Benzene and benzene derivatives (e.g., airplane glue, paint remover, dry-cleaning solutions) - Toxic materials, such as inorganic arsenic, glycol ethers, plutonium, and radon - **Clinical Manifestations** - Anemia - fatigue, pallor, dyspnea - Leukopenia -- risk for infection (repeated throat infections -- lymphadenopathy) - Thrombocytopenia -- risk for bleeding (Purpura or bruising, retinal hemorrhages) - **Diagnostic Findings** - CBC -- pancytopenia (a decrease in all myeloid stem cell--derived cells) - Bone marrow aspirate shows an extremely hypoplastic or even aplastic (very few to no cells) marrow replaced with fat - **Medical Management** - Hematopoietic stem cell transplant (HSCT) - Immunosuppressive therapy - combination of antithymocyte globulin (ATG) and cyclosporine or androgens - ATG - purified gamma-globulin solution, is obtained from horses or rabbits immunized with human T lymphocytes - Side effects - fever and chills during infusion - WOF anaphylaxis - sudden onset of a rash or bronchospasm - Transfusions of PRBCs and platelets as necessary - **Nursing Management** - Assess for signs of infection and bleeding - Monitor for side effects of therapy, particularly for hypersensitivity reaction while administering ATG - Long-term cyclosporine therapy - monitor for long-term effects, including renal or liver dysfunction, hypertension, pruritus, visual impairment, tremor, and skin cancer - Do not stop medications abruptly C. **Megaloblastic Anemias** - anemia caused by deficiencies of vitamin B12 or folic acid - identical bone marrow and peripheral blood changes occur because both vitamins are essential for normal DNA synthesis - the erythrocytes that are produced are abnormally large and called ***megaloblastic red cells*** - other cells derived from the myeloid stem cell (nonlymphoid leukocytes, platelets) are also abnormal - A bone marrow analysis reveals hyperplasia (an abnormal increase in the number of cells), and the precursor erythroid and myeloid cells are large and bizarre in appearance - Many of these abnormal erythroid and myeloid cells are destroyed within the marrow, so the mature cells that do leave the\ marrow are actually fewer in number (pancytopenia can develop) - **Folic Acid Deficiency** - Deficient intake of folic rich foods (green vegetables and liver) - Alcoholism - Liver disease - Chronic hemolytic anemias - Pregnancy - Malabsorption - **Vitamin B12 Deficiency (Pernicious Anemia)** - Inadequate dietary intake (vegans) - Faulty absorption from the GI tract - Crohn's disease or after ileal resection, bariatric surgery, or gastrectomy - Chronic use of histamine blockers, antacids, or proton pump inhibitors to reduce gastric acid production can also inhibit\ B12 absorption - Absence of intrinsic factor - **Clinical Manifestations -** symptoms of folic acid and vitamin B12 deficiencies are similar, and the two anemias may coexist - **Pernicious Anemia** - Neurologic manifestations - Weakness - Listlessness - Fatigue - Smooth, sore, red tongue - Extremely pale, particularly in the mucous membranes - Paresthesias in the extremities - Difficulty maintaining balance - Loss of position sense (proprioception) - **Medical Management** - Folate deficiency - Increase amount of folic acid in the diet - Administer 1 mg of folic acid daily - Folic acid IM only to people with malabsorption problems - Vitamin B12 deficiency - Oral supplements with vitamins or fortified soy milk - Monthly intramuscular injections of vitamin B12 (lack of intrinsic factor) - **Nursing Management** - Inspect skin, mucous membranes, and tongue - Mild jaundice may be apparent and is best seen in the sclera without using fluorescent lights - Vitiligo (patchy loss of skin pigmentation) and premature graying of the hair are often seen in patients with pernicious\ anemia - Careful neurologic assessment is important - If sensation is altered, the patient needs to be instructed to avoid excessive heat and cold - Pay particular attention to ambulation and assess the patient's gait and stability - Eat small amounts of bland, soft foods frequently