Infectious, Inflammatory, and Immune Response (Acute and Chronic) Part 1 PDF

Infectious, Inflammatory, and Immune Response (Acute and Chronic) Part 1 Pauline Kaye S. De Leon, MD The Infectious Process The Chain of Infection A complete chain of events is necessary for infection to occur. Six elements are necessary, including a causative organism,...

Infectious, Inflammatory, and Immune Response (Acute and Chronic) Part 1 Pauline Kaye S. De Leon, MD The Infectious Process The Chain of Infection A complete chain of events is necessary for infection to occur. Six elements are necessary, including a causative organism, a reservoir of available organisms, a portal of exit from the reservoir, a mode of transmission from the reservoir to the host (an organism that provides living conditions to support a microorganism) and a mode of entry into a susceptible host. The Chain of Infection Causative organism types of microorganisms that cause infections are bacteria, rickettsiae, viruses, protozoa, fungi, and helminths. Reservoir term used for any person, plant, animal, substance, or location that provides nourishment for microorganisms and enables further dispersal of the organism. Infections may be prevented by eliminating the causative organisms from the reservoir. The Chain of Infection Portal of Exit organism must have a portal of exit from a reservoir. An infected host must shed organisms to another or to the environment for transmission to occur. Organisms exit through the respiratory tract, the gastrointestinal tract, the genitourinary tract, or the blood. Route of Transmission route of transmission is necessary to connect the infectious source with its new host. Organisms may be transmitted through food intake, sexual contact, skin- to-skin contact, percutaneous injection, or infectious particles carried in the air. The Chain of Infection Route of Transmission A person who carries or transmits a pathogen but does not have apparent signs and symptoms of infection is called a carrier. Specific organisms require specific routes of transmission for infection to occur. Susceptible host For infection to occur, the host must be susceptible (not possessing immunity to a pathogen). Previous infection or vaccine administration may render the host immune (not susceptible) to further infection with an agent. The Chain of Infection Susceptible host A person who is immunosuppressed has much greater susceptibility to infection than a healthy person. Portal of Entry needed for the organism to gain access to the host. Colonization, Infection, and Infectious Disease Relatively few anatomic sites (e.g., brain, blood, bone, heart, vascular system) are sterile. Bacteria found throughout the body usually provide beneficial normal flora (nonpathogenic organisms colonizing a host) to compete with potential pathogens, to facilitate digestion, or to work in other ways symbiotically with the host. Colonization, Infection, and Infectious Disease Colonization used to describe the presence of microorganisms without host interference or interaction. Organisms reported in microbiology test results often reflect colonization rather than infection. Infection indicates a host interaction with an organism. Infection is recognized by the host reaction (manifested by signs and symptoms) and by laboratory-based evidence of white blood cell reaction and microbiologic organism identification. Colonization, Infection, and Infectious Disease Infectious Disease is the state in which the infected host displays a decline in wellness due to the infection. When the host interacts immunologically with an organism but remains symptom free, the definition of infectious disease has not been met. This is considered latency, or the time interval after primary infection when a microorganism lives within the host without producing clinical evidence of disease. The severity of an infectious disease ranges from mild to life-threatening Host defense mechanism Host defense mechanism Our bodies are constantly under attack by an army of microorganisms, toxins, allergens, and other substances that are recognized as foreign (non-self). The ways in which the body protects itself from pathogens can be thought as an army consisting of three lines of defense.  An immune response is a physiological process coordinated by the immune system to eliminate foreign substances (antigens). Our immune system includes two key branches: innate and adaptive immunity. The three common features of both branches are that they Recognize diverse pathogens, Eliminate identified invaders, and Discriminate between self and foreign antigens. Physical (Anatomical) Barriers Intact skin covered by outer tough layer that successfully prevents the entry of pathogens, but when the skin is damaged as in burns, traumatic injury, or surgery, infectious can be a serious problem Intact mucosal lining Acts as a protective barrier to block the adherence of bacteria to epithelial cells Nasal hair Don’t allow dust particles and microorganisms enter the respiratory tract Earwax A sticky substance that traps microbes and makes tissue invasion more difficult. Chemical Barriers There are a number of chemical barriers that control microbial growth: Fatty acids of skin, acid pH of swear and sebaceous secretions inhibit growth of microorganisms, due to their bactericidal effect. Lysozyme present in tears, nasal secretions, and saliva and in most secretion except in CSF, degrades peptidoglycan, an essential element present in bacterial cell wall Spermine and zinc in the semen have bactericidal effect. Lactoperoxidase in milk has bactericidal action. Gastric juice is produced by the glands of the stomach Vaginal secretions play a role in antibacterial activity. Normal Microbiota (Flora) The normal microbiota is the group of microorganisms routinely found growing on the body of healthy individuals. The community is also called the microbiome. Microbes that typically inhabit body sites for extended periods are resident microbiota, whereas temporary occupants are transient microbiota. Normal Microbiota (Flora) The normal microbiota prevents pathogens from colonizing the host by competing with them for nutrients, by producing substances that are harmful to the pathogens, and by altering conditions that affect the survival of the pathogens, such as pH and oxygen availability. Innate Cellular and Molecular Defenses For its second line of defense, the body uses an enormous number of cells and chemicals. These defense rely on the destructive powers of cells called phagocytes and natural killer cells, on the inflammatory response, and on a variety of chemical substances that kill pathogens and help repair tissue. Fever A nonspecific protective response A systemic response to invading microorganisms which is different from the “local heat” that characterizes inflammation Infectious agents trigger fever, fever-inducing agents are called pyrogens Pyrogens trigger the release of cytokines, which signal the hypothalamus to raise the body’s baseline temperature Although high fever is dangerous because excess heat “scrambles” enzymes and other body proteins rendering them nonfunctional, mild or moderate fever seems to benefit the body Inflammation An innate immune response that tends to develop when our tissues are damaged, either from physical factors like trauma or burns, or from infectious agents Two types of Inflammation Acute inflammation Chronic inflammation Cellular Second Line Defense: Phagocytosis Phagocytes are cells that literally eat or engulf other materials. They patrol, or circulate through the body, destroying dead cells and cellular debris that must be removed constantly from the body as cells die and are replaced. Being present in many tissues, these cells first attack microbes and other foreign material at portals of entry. If some microbes escape destruction at the portal of entry and enter deeper tissues, phagocytes circulating in blood or lymph mount a second attack on them. Process of Phagocytosis Several types of cells in the immune system engulf microorganisms via phagocytosis, which are mainly: Neutrophils, Macrophages, Dendritic cells, and B lymphocytes If an infection occurs, phagocytic cells use this four-step process to destroy the invading microorganisms Recognition, Adherence, Engulfment, and Intracellular killing Molecular Second Line Defense A number of defense molecules mediate innate immune responses which includes: Antimicrobial proteins Proteins that act as chemical barriers by destroying a wide spectrum of viruses, parasites, bacteria, and fungi Interferons A collection of signaling molecules give the alarm when pathogens or tumor cells are detected. Well known for anti-viral effects and derive their name from their ability to “interfere” with viral replication Molecular Second Line Defense Iron-binding proteins If access to iron is limited, then so is cell growth and survival. Acute phase response A rapid, systemic increase in various plasma proteins in response to innate inflammation Complement systems Stimulate inflammation Tag targets for elimination Directly kill targeted cells by cytolysis Inflammatory Response Cellular Response to Injury: Inflammation Cells or tissues of the body may be injured or killed by any of the agents (physical, chemical, infectious) When this happens, an inflammatory response (or inflammation) naturally occurs in the healthy tissues adjacent to the site of injury. Inflammation a localized reaction intended to neutralize, control, or eliminate the offending agent to prepare the site for repair It is a nonspecific response (not dependent on a particular cause) that is meant to serve a protective function also occurs in cell injury events, such as stroke, deep vein thrombosis, and myocardial infarction. not the same as infection. An infectious agent is only one of several agents that may trigger an inflammatory response. Inflammation Regardless of the cause, a general sequence of events occurs in the local inflammatory response. This sequence involves changes in the microcirculation, including vasodilation, increased vascular permeability, and leukocytic cellular infiltration As these changes take place, five cardinal signs of inflammation are produced: redness, warmth, swelling, pain, and loss of function Inflammation Local warmth and redness is caused by The transient vasoconstriction that occurs immediately after injury is followed by vasodilation and an increased rate of blood flow through the microcirculation to the area of tissue damage. Swelling the structure of the microvascular system changes to accommodate the movement of plasma protein from the blood into the tissues. Following this increase in vascular permeability, plasma fluids (including proteins and solutes) leak into the inflamed tissues Inflammation Leukocytes migrate through the endothelium and accumulate in the tissue at the site of the injury. Pain occurs is attributed to the pressure of fluids or swelling on nerve endings and to the irritation of nerve endings by chemical mediators released at the site. Loss of function is most likely related to the pain and swelling; however, the exact mechanism is not completely known. Types of Inflammation Inflammation is categorized primarily by its duration and the type of exudate produced. Acute inflammation characterized by the local vascular and exudative changes described previously and usually lasts less than 2 weeks An acute inflammatory response is immediate and serves a protective function. After the causative agent is removed, the inflammation subsides, and healing takes place with the return of normal or near-normal structure and function. Inflammation Chronic inflammation develops if the injurious agent persists and the acute response is perpetuated. Symptoms are present for many months or years. may also begin insidiously and never have an acute phase. The chronic response does not serve a beneficial and protective function; on the contrary, it is debilitating and can produce long- lasting effects. Inflammation Chronic inflammation As the inflammation becomes chronic, changes occur at the site of injury, and the nature of the exudate becomes proliferative. A cycle of cellular infiltration, necrosis, and fibrosis begins, with repair and breakdown occurring simultaneously. Considerable scarring may occur, resulting in permanent tissue damage. Cellular Healing reparative process begins at approximately the same time as the injury. Healing proceeds after the inflammatory debris has been removed. Healing may occur by regeneration, in which the defect is gradually repaired by proliferation of the same type of cells as those destroyed, or by replacement, in which cells of another type, usually connective tissue, fill in the tissue defect and result in scar formation. Cellular Healing Regeneration ability of cells to regenerate depends on whether they are labile, permanent, or stable. Labile cells multiply constantly to replace cells worn out by normal physiologic processes Permanent cells include neurons—the nerve cell bodies, not their axons. Destruction of neurons is permanent; however, axons may regenerate Cellular Healing Stable cells in some organ systems have a latent ability to regenerate. Under normal physiologic processes, they are not shed and do not need replacement; if they are damaged or destroyed, they are able to regenerate. Cellular Healing Replacement The condition of the host, the environment, and the nature and severity of the injury affect the processes of inflammation, repair, and replacement. Depending on the extent of damage, repair and replacement may occur by primary or secondary intention. In primary intention healing, the wound edges are approximated, as in a surgical wound. Little scar formation occurs, and the wound healing occurs without granulation. Cellular Healing In secondary intention healing, there is tissue loss so the edges are not approximated and the wound fills with granulation tissue The process of repair takes longer and may result in scar formation, with loss of specialized function. Infection Control and Prevention Infection Control and Prevention The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) are the principal agencies involved in setting guidelines about infection prevention. The impact of infectious diseases changes over time as microorganisms mutate, as human behavior patterns shift, or as therapeutic options change. Preventing Infection in Health Care Setting prevention of infection in the health care setting focuses upon following the appropriate standard and transmission-based precautions as well as reducing the risk of a health care– associated infection (HAI). HAIs, formerly called nosocomial infections, are infections that were not present or incubating at the time of the patient’s admission to the health care setting. Isolation Precautions are guidelines created to prevent transmission of microorganisms in health care facilities The first tier, called standard precautions, is designed for the care of all patients and is the primary strategy for preventing HAIs. The second tier, called transmission-based precautions, is designed for care of patients with known or suspected infectious diseases spread by airborne, droplet, or contact routes Standard Precautions The basis of standard precautions is that all patients are colonized or infected with microorganisms, whether or not there are signs or symptoms, and that a uniform level of caution should be used in the care of all patients. The health care worker should use additional barriers in the form of personal protective equipment (PPE), including gloves, masks, eye protection, and cover gowns, depending on the expected degree of exposure to patient excretions or secretions. Standard Precautions: Hand Hygiene most frequent cause of bacterial transmission in health care institutions is spread of microorganisms by the hands of health care workers. Standard Precautions: Hand Hygiene Effective handwashing requires at least 20 seconds of vigorous scrubbing, with special attention to the area around nail beds and between fingers, where there is a high bacterial load. Hands should be thoroughly rinsed after washing. If hands are not visibly soiled, health care providers are encouraged to use alcohol-based, waterless antiseptic agents for routine hand decontamination. Hand hygiene decreases bacterial transmission to patients by reducing bacterial load on health care workers’ hands. Standard Precautions: Hand Hygiene Artificial fingernails or nail extenders have been epidemiologically linked to several significant infection outbreaks and therefore should not be worn when providing patient care. Natural nails should be kept less than 0.6 cm (0.25 inch) long, and nail polish should be removed when chipped because it can support increased bacterial growth Standard Precautions: Glove use Gloves provide an effective barrier for hands from the microflora associated with patient care. Gloves should be worn when a health care worker has contact with any patient secretions or excretions and must be discarded after each patient care contact. Because microbial organisms colonizing health care workers’ hands can proliferate in the warm, moist environment provided by gloves, hands must be washed or disinfected after gloves are removed. Standard Precautions: Glove use As patient advocates, nurses have an important role in promoting hand hygiene and glove use by other hospital workers. Compared with vinyl gloves, latex or nitrile gloves are preferred because they resist puncture better and provide greater comfort and fit. Standard Precautions: Needlestick Prevention most important aspect of reducing the risk of bloodborne infection is avoidance of percutaneous injury Used needles should not be recapped. Instead, they are placed directly into puncture-resistant containers close to where they are used. If a situation dictates that a needle must be recapped, the nurse must use a mechanical device to hold the cap or use a one- handed approach to decrease the likelihood of skin puncture. Standard Precautions: Avoidance of splash and sprays When the health care professional is involved in an activity in which body fluids may be sprayed or splashed, appropriate barriers must be used. If a splash to the face may occur, goggles and a facemask are warranted. If the health care worker is involved in a procedure in which clothing may be contaminated with biologic material, a cover gown should be worn Transmission-based Precautions Reducing the risk of HAIs requires specific preventive activities in addition to implementing standard precautions. Transmission-based categories are airborne, droplet, and contact precautions. Precautions are based on the routes of transmission Diseases spread by very small respiratory particles that are suspended as aerosol require airborne precautions, those spread by larger respiratory droplets require droplet precautions, and those spread by touch require contact precautions. Transmission-based Precautions: Airborne Precautions are required for patients with presumed or proven pulmonary TB, varicella, or other airborne pathogens such as COVID-19. When hospitalized, patients should be in airborne infection isolation rooms, engineered to provide negative air pressure, rapid turnover of air, and air either highly filtered or exhausted directly to the outside. If a facility does not have negative pressure rooms available, portable high-efficiency particular air (HEPA) filters may be used. Health care providers should wear an N95 respirator. Transmission-based Precautions: Droplet Precautions used for organisms such as influenza or meningococcus that can be transmitted by close contact with respiratory or pharyngeal secretions. When caring for a patient requiring droplet precautions, the nurse should wear a facemask within 3 to 6 feet of the patient; however, because the risk of transmission is limited to close contact, the door may remain open. Transmission-based Precautions: Contact Precautions used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or C. difficile. Contact precautions are designed to emphasize cautious technique and the use of barriers. Masks are not needed, and doors do not need to be closed Preventing Infection in the Community Methods of infection prevention include sanitation techniques (e.g., water purification, disposal of sewage and other potentially infectious materials), regulated health practices (e.g., the handling, storage, packaging, and preparation of food by institutions), and immunization programs. Most infections occur in the community, out of health care settings. Local epidemics and pandemics are the most significant type of community-acquired infections. Preventing Infection in the Community Pandemics are usually caused by novel viruses which begin to circulate among a population that universally has no immunity. The epidemiologic definition of a pandemic, based on the degree of spread, has often been used socially to instead convey disaster. The frequency and severity of pandemics cannot be accurately predicted, but models suggest that even a medium-intensity pandemic can quickly overwhelm the existing health care infrastructure Preventing Infection in the Community Nurses play a crucial role during a pandemic as they provide care while themselves becoming potentially exposed. During these times, nurses demonstrate the importance of following standard precautions and transmission-based precautions. Vaccination Programs goal of vaccination programs is to use wide-scale efforts to prevent specific infectious diseases from occurring in a population Risks and benefits for the person and the community must be evaluated in terms of morbidity, mortality, and financial cost and benefit. Successful vaccine programs have reduced the incidence of many infectious diseases Vaccination Programs Vaccines are suspensions of antigen preparations that are intended to produce a human immune response to protect the host from future encounters with the organism. The two principal schedules are for children and adults Variations to the recommended immunization schedule should be made on a case-by-case basis, depending on the patient’s risk factors as well as likely exposures.  Health care workers should be immune to measles, mumps, rubella, pertussis, tetanus, hepatitis B, and varicella. Individual and epidemic risks are reduced when vaccination campaigns reach all communities. Home-based care of patients with infectious diseases Home-based care of patients with infectious diseases nurse who cares for the patient with an infectious disease in the home should provide information about infection risk prevention to the patient, the family, and the caregiver The nurse should establish a work environment that facilitates hand hygiene and aseptic technique Family caregivers should receive an annual influenza vaccine. This is especially true if the caregiver or the patient is older than 50 years, has underlying cardiac or pulmonary disease, or has underlying immunosuppression. Reducing Risk to the Patient: Equipment Care All caregivers must pay careful attention to disinfection and aseptic technique while providing care and using medical equipment. Catheter-related sepsis should be suspected in a patient who has unexplained fever, redness, swelling, and drainage around a vascular catheter insertion site. Reducing Risk to the Patient: Patient Education When assessing the risk of infection in the home environment of the patient who is immunosuppressed, it is important to realize that intrinsic colonizing bacteria and latent viral infections present a greater risk than do extrinsic environmental contaminants. The nurse should reassure the patient and family that their home needs to be clean but not sterile. Reducing Risk to the Patient: Patient Education For patients with neutropenia or T-cell dysfunction (e.g., patients with acquired immune deficiency syndrome [AIDS]), it is wise to restrict visits of people with potentially contagious illnesses. The patient who is immunosuppressed is vulnerable to acquiring bacterial infection with enteric pathogens from food; therefore, family members should be reminded about the need to follow recommendations for hygiene, storage, and safe cooking times and temperatures. Reducing Risk to Household Members Establishing reasonable barriers to infection transmission in the household is an important part of home care. The route of transmission of the organism in question must first be determined. The nurse can then educate household members about strategies to reduce their risk of becoming infected. Reducing Risk to Household Members If the patient has active pulmonary TB, the public health department should be contacted to provide screening and treatment for family members. If the patient has herpes zoster, family members who have had varicella vaccine or who have previously had chickenpox are considered immune and need no precautions. Reducing Risk to Household Members Family members who assist in the care of a patient with a bloodborne infection such as HIV or hepatitis C can prevent transmission by carefully handling any sharp objects that are contaminated with blood. Family members should be reassured that dishes are safe to use after being washed with hot water and that linens and clothing are safe to use after being washed in a hot water cycle. Nursing Management Assessment A careful history along with a review of the patient’s medical record will determine current symptoms and underlying conditions. Physical examination may reveal signs of infection. Nursing interventions Preventing Infection Transmission Preventing the spread of infection requires an understanding of the usual routes of transmission of the organism. strict adherence to isolation measures is important to reduce the opportunity for spread. Preventing transmission of organisms from patient to patient requires participation of all members of the health care team Nursing Management Nursing interventions Educating Patient about Infectious Process educate the patient to understand the diagnosis and to adhere to the treatment regimen Nurses are key to educating patients about guidelines for preventing transmission of infectious diseases stress the importance of immunization to parents of young children and to others for whom vaccines are recommended, such as older adults or those who are immunosuppressed or have chronic illness or disability. Nursing Management Nursing interventions Monitoring and Managing Potential Complications patient with a rapidly progressive infectious disease should have vital signs and level of consciousness closely monitored. Diarrheal Diseases Diarrheal Diseases are a significant cause of mortality, especially for children Water disinfection, pasteurization, and appropriate food packaging have decreased the incidence of diseases such as typhoid and cholera. Diarrheal Diseases: Transmission portal of entry of diarrheal pathogens is oral ingestion Infection can occur when the infectious dose is high enough or if the acidic digestive environment is neutralized Decreased gastric acidity with disruption of normal bowel flora (as occurs after surgery), the use of antimicrobial agents, and other causes of immune suppression decrease intestinal defenses. Diarrheal Diseases: Causes There are many viral, bacterial, and parasitic causes of diarrheal diseases. The most significant viral cause of diarrhea is the Calicivirus (often called Norovirus, a virus associated with outbreaks in long-term care facilities and cruise ships) Common causes of bacterial infection include Campylobacter, Salmonella, Shigella, and E. coli. A common parasitic infection of importance is Giardia. Diarrheal disease may also be caused by Vibrio cholera. Nursing Interventions Nursing interventions table for diarrheal disease can be found in Brunner & Suddarth’s Textbook of Medical and Surgical Nursing 15th edition, Chapter 66 - Diarrheal Diseases Please read the table. Calicivirus (Norovirus) often referred to as the Norovirus, is the most common cause of foodborne illness and gastroenteritis in the United States. Onset of illness is usually acute, with vomiting and watery diarrhea that generally last for approximately 2 days. transmitted easily from person to person by direct contact and by ingesting contaminated food. Although people with Calicivirus infection typically recover within 2 to 3 days, they may continue to transmit the virus to others for approximately 2 more weeks Calicivirus (Norovirus) can withstand environmental extremes of heat or cold and are resistant to chemical disinfection, which are significant reasons for their epidemic potential. CDC recommends disinfecting surfaces with a freshly prepared bleach solution, with 5 to 25 tablespoons of bleach per gallon of water, or other product that is approved by the Environmental Protection Agency (EPA) for Norovirus disinfection Campylobacter infections are frequent causes of diarrheal disease in the United States The bacterium, which is abundant in animal foods, is especially common in poultry but can also be found in beef and pork. Cooking and storing food at appropriate temperatures protect against Campylobacter infection. Kitchen utensils used in meat preparation must be kept away from other food to prevent transmission from Campylobacter and other foodborne organisms Campylobacter infections After a person is infected, the bacterium directly attacks the lumen of the intestine and may cause disease through enterotoxin release. Symptoms can range from mild abdominal cramping and minimal diarrhea to severe disease with profuse watery bloody diarrhea and debilitating abdominal cramping. Antimicrobial therapy is recommended only for patients who are seriously ill Salmonella infection Salmonella is a gram-negative bacillus with many species, including the very pathogenic Salmonella typhi (cause of typhoid fever). Of the nontyphi species, most organisms are prevalent in animal food sources, especially eggs and chicken. Salmonella infections produce variable symptoms, including an asymptomatic carrier state, gastroenteritis, and systemic infection. Diarrhea with gastroenteritis is common. Disseminated disease and bacteremia, sometimes accompanied by diarrhea, occur less often. Shigella infection Shigella species are gram-negative organisms that invade the lumen of the intestine and can cause severe watery (sometimes bloody) diarrhea and disseminated disease. Shigella species are spread through the fecal–oral route, with easy transmission from one person to another. Escherichia coli E. coli is the most common aerobic organism colonizing the large bowel. more pathologic strains are subgrouped as Shiga toxin–producing Escherichia coli (STEC) because of their production of enterotoxins. STEC strains often cause choleralike disease, with rapid, severe dehydration and an increased risk of death. Escherichia coli Prevention of disease from STEC strains is aimed at educating the public to wash fruits and vegetables thoroughly, to separate foods during preparation, and to use a food thermometer to assure meat has been cooked thoroughly Giardia lamblia Transmission of the protozoan Giardia lamblia occurs when food or drink is contaminated with viable cysts of the organism. People often become infected while traveling to endemic areas or by drinking contaminated water from mountain streams The organism can be transmitted by close contact, such as occurs in day care settings. Transmission by sexual contact has also been documented. CDC recommends metronidazole to treat Giardia Vibrio cholerae The causative organism is transmitted by contaminated food or water. Cholera causes disease with a very rapid onset of copious diarrhea in which up to 1 L of fluid per hour can be lost. Dehydration, with subsequent cardiopulmonary collapse, may cause rapid progression from onset of signs and symptoms to death. Rehydration efforts should be vigorous and sustained. If oral rehydration cannot be accomplished, the patient may need IV fluid replacement Nursing Process: Patient with Infectious Diarrhea Assessment most important element of assessment in the patient with diarrhea is to determine hydration status includes evaluation for thirst, dryness of oral mucous membranes, sunken eyes, a weakened pulse, and loss of skin turgor. Intake and output measurements are crucial in determining fluid balance. asks the patient what they have eaten recently and about recent travel, treatment with antibiotics, and potential exposure to others with diarrheal disease Nursing Process: Patient with Infectious Diarrhea Diagnosis Hypovolemia associated with fluid lost through diarrhea Lack of knowledge about the infection and the risk of transmission to others Potential complications may include the following: Bacteremia Hypovolemic shock Planning and Goals maintenance of fluid and electrolyte balance, increased knowledge about the disease and risk of transmission, and absence of complications Nursing Process: Patient with Infectious Diarrhea Nursing Interventions Correcting dehydration associated with diarrhea Oral rehydration therapy is a strategy used to reduce the severe complications of diarrheal disease regardless of causative agent. Mild dehydration patient exhibits dry oral mucous membranes of the mouth and increased thirst. The rehydration goal at this level of dehydration is to deliver about 50 mL of ORS per 1 kg of weight over a 4-hour interval Nursing Process: Patient with Infectious Diarrhea Correcting dehydration associated with diarrhea Moderate dehydration Common findings are sunken eyes, loss of skin turgor, increased thirst, and dry oral mucous membranes. The rehydration goal at this level of dehydration is to deliver about 100 mL/kg of ORS over 4 hours. Severe dehydration The patient with severe dehydration shows signs of shock (i.e., rapid thready pulse, cyanosis, cold extremities, rapid breathing, lethargy, or coma; and should receive IV replacement until hemodynamic and mental status return to normal. When improvement is evident, the patient can be treated with ORS. Nursing Process: Patient with Infectious Diarrhea Administering Rehydration therapy Oral rehydration therapy should be delivered frequently in small amounts. When patients are persistently vomiting, they often require frequent administration of fluids by spoonfuls. IV therapy is necessary for the patient who is severely dehydrated or in shock. Increasing knowledge and preventing spread of infection Public health nurses, school nurses, and others who are involved in patient education should emphasize principles of safe food preparation, with special attention to meat, poultry, and fish preparation and cooking Nursing Process: Patient with Infectious Diarrhea Evaluation Expected patient outcomes may include: Attains fluid balance Acquires knowledge and understanding about infectious diarrhea and transmission potential Absence of complications Sexually Transmitted Infections Sexually Transmitted Infections are diseases acquired through sexual contact with a person who is infected STIs are the most common infectious diseases in the United States and are epidemic in most parts of the world. Portals of entry of STI-causing microorganisms and sites of infection include the skin and mucosal linings of the urethra, cervix, vagina, rectum, and oropharynx. Sexually Transmitted Infections Education about prevention of STIs includes information about risk factors and behaviors that can lead to infection. STIs may progress without symptoms, and a delay in diagnosis and treatment is potentially harmful because the risk of complications for the person who is infected and the risk of transmission to others increase over time. Sexually Transmitted Infections Infection with one STI suggests the possibility of infection with other diseases as well. After one STI is identified, diagnostic evaluation for others should be conducted. The possibility of HIV infection should be pursued when any STI is diagnosed. Syphilis is an acute and chronic infectious disease caused by the spirochete Treponema pallidum It is acquired through sexual contact or may be congenital in origin. Stages of Syphilis Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. Painless lesions at the site of infection, called chancres, usually resolve spontaneously within 3 to 12 weeks, with or without treatment Syphilis Stages of Syphilis Secondary syphilis occurs by hematogenous spread leading to generalized infection. The rash of secondary syphilis occurs from 1 week to 6 months after the chancre. Transmission can occur through contact with these lesions. Generalized signs of infection may include lymphadenopathy, arthritis, meningitis, hair loss, fever, malaise, and weight loss After the secondary stage, there is a period of latency, when the person who is infected has no signs or symptoms of syphilis. Syphilis Stages of Syphilis Tertiary syphilis is the final stage in the natural history of the disease. It is estimated that between 20% and 40% of those infected do not exhibit signs and symptoms in this final stage. may present as a slowly progressive inflammatory disease with the potential to affect multiple organs. The most common manifestations at this level are aortitis and neurosyphilis, as evidenced by dementia, psychosis, paresis, stroke, or meningitis Syphilis Assessment and Diagnostic findings Nontreponemal or reagin tests, such as the Venereal Disease Research Laboratory (VDRL) or the rapid plasma reagin circle test (RPR-CT), are generally used for screening and diagnosis. Treponemal tests, such as the fluorescent treponemal antibody absorption (FTA-ABS) test and the microhemagglutination test for Treponema pallidum (MHA-TP), are used to verify that the screening test did not represent a false-positive result. Positive results usually are positive for life Syphilis Medical management Treatment of all stages of syphilis is administration of antibiotic medications. Intramuscular Penicillin G benzathine is the medication of choice for early syphilis or early latent syphilis of less than 1 year’s duration. Patients with late latent or latent syphilis of unknown duration should receive three injections at 1-week intervals. Patients who are allergic to penicillin are usually treated with doxycycline. Syphilis Nursing management Syphilis is a reportable communicable disease patients who are diagnosed are reported to the state or local public health department to ensure community follow- up. The public health department is responsible for identification of sexual contacts, contact notification, and contact screening. Lesions of primary and secondary syphilis may be highly infective. Gloves are worn when direct contact with lesions is likely, and hand hygiene is performed after gloves are removed. Isolation in a private room is not required Chlamydia trachomatis and Neisseria gonorrhea are the most commonly reported infectious diseases in the United States. Coinfection with C. trachomatis often occurs in patients infected with N. gonorrhoeae. The greatest risk of C. trachomatis infection occurs in young women between 15 and 24 years of age Both C. trachomatis and N. gonorrhoeae infections frequently do not cause symptoms in women Chlamydia trachomatis and Neisseria gonorrhea When symptoms are present, mucopurulent cervicitis with exudates in the endocervical canal is the most frequent finding. Women with gonorrhea can also present with symptoms of urinary tract infection or vaginitis. In men, symptoms are present, they may include burning during urination and penile discharge. Patients with N. gonorrhoeae infection may also report painful, swollen testicles Chlamydia trachomatis and Neisseria gonorrhea Assessment and Diagnostic finding Diagnostic methods used in N. gonorrhoeae infection include Gram stain (appropriate only for male urethral samples), culture, and nucleic acid amplification tests (NAATs). Gram stain and the direct fluorescent antibody test can be used in chlamydia. NAATs are also available for C. trachomatis. Chlamydia trachomatis and Neisseria gonorrhea Medical management Because patients are often coinfected with both gonorrhea and chlamydia, dual therapy is recommended, even if only gonorrhea has been laboratory proven Nursing management Gonorrhea and chlamydia are reportable communicable diseases. In any health care facility, a mechanism should be in place to ensure that all patients who are diagnosed are reported to the local public health department to ensure follow-up of the patient Chlamydia trachomatis and Neisseria gonorrhea Nursing management The target group for preventive patient education about gonorrhea and chlamydia is the adolescent and young adult population Nursing Process: Patient with STI Assessment patient should be asked to describe the onset and progression of symptoms and to characterize any lesions by location and by describing drainage, if present. When obtaining a sexual history, the CDC recommends the following systematic interview of key areas, the “five Ps”: partners, prevention of pregnancy, protection from STIs, practices, and past history of STIs. Nursing Process: Patient with STI Assessment During the physical examination, the examiner looks for rashes, lesions, drainage, discharge, or swelling. Inguinal nodes are palpated to elicit tenderness and to assess swelling. Women are examined for abdominal or uterine tenderness. The mouth and throat are examined for signs of inflammation or exudate. The nurse wears gloves while examining the mucous membranes, and gloves are changed and replaced after vaginal or rectal examination Nursing Process: Patient with STI Diagnosis Lack of knowledge about the disease and risk for spread of infection and reinfection Anxiety associated with anticipated stigmatization and to prognosis and complications Impaired ability to manage regime associated with integrating a therapeutic regimen for treatment Nursing Process: Patient with STI Diagnosis Potential complications may include the following: Ectopic pregnancy Infertility Transmission of infection to fetus, resulting in congenital abnormalities and other outcomes Neurosyphilis Gonococcal meningitis Gonococcal arthritis Syphilitic aortitis HIV-related complications Nursing Process: Patient with STI Planning and Goals increased patient understanding of the natural history and treatment of the infection, reduction in anxiety, increased adherence with therapeutic and preventive goals, and absence of complications. Nursing Process: Patient with STI Nursing interventions Increasing knowledge and preventing spread of disease Education about STIs and prevention of the spread to others are often accomplished simultaneously. Reducing anxiety When appropriate, the patient is encouraged to discuss anxieties and fear associated with the diagnosis, treatment, or prognosis. Increasing adherence In group settings (e.g., an outpatient obstetric setting) or in a one-to-one setting, open discussion about STI information facilitates patient education. Nursing Process: Patient with STI Evaluation Exhibits knowledge about STIs and their transmission Demonstrates a less anxious demeanor Adheres to treatment Achieves effective treatment Reports for follow-up examinations if necessary Absence of complications Emerging Infectious Diseases Emerging Infectious Diseases are human diseases of infectious origin that have increased within the past two decades or that are likely to increase in the near future. Examples of emerging infectious diseases presented here include COVID-19, Zika virus, West Nile virus, Ebola virus disease, Legionnaires disease, and pertussis Bioterrorism agents such as anthrax and plague are also considered emerging infectious diseases because a bioterrorist act would introduce a new mode of transmission for these agents Emerging Infectious Diseases Infectious diseases may begin anywhere in the world Elaborate disease surveillance and reporting methods are established with the goal of early detection and control of actual and potential epidemics and pandemics COVID-19 COVID-19 pandemic began in Wuhan, China, in late 2019 transmission occurs through virus-laden droplets and aerosols exhaled by an infected host while breathing, speaking, coughing, and sneezing Individuals of any age, gender, and ethnicity can be at risk for infection; however, adults 65 years of age and older, and those who reside in long-term care or skilled nursing facilities are at higher risk of death from COVID-19 COVID-19 mild COVID-19 manifestations may include fever, nonproductive cough, sore throat, fatigue, myalgias (muscle aches), nasal congestion, nausea, vomiting, diarrhea, anosmia (loss of smell), and ageusia (loss of taste) Patients with mild symptoms, about 80% of patients, can be managed at home. Those with severe illness are hospitalized. Nasopharyngeal samples are the recommended method of diagnosing SARS-CoV-2 COVID-19 Two SARS-CoV-2 mRNA vaccines were authorized for emergency use in the United States in December of 2020 Nursing management of the patient with COVID-19 mirrors that of medical management. The nurse should also encourage frequent handwashing with at least 20 seconds of scrubbing, rinsing, and drying after washing (CDC, 2002). If handwashing is not possible, then hand sanitizer with at least 60% alcohol should be used. Zika Virus first discovered as a pathogen in monkeys in the Zika Forest of Uganda in the 1940s; it was found to cause human disease in the 1950s epidemiologic pattern changed as the first large outbreak in humans did not occur until 2007 in Micronesia disease was not seen in the Western Hemisphere until July 2015, when a large outbreak began in Brazil incubation period for Zika virus disease is estimated to be between 3 and 14 days Zika Virus Zika has been associated with microcephaly and other congenital abnormalities in infants of some women infected with Zika during pregnancy primarily transmitted through bites of infected mosquitos from the Aedes genus. can also be transmitted through sexual transmission West Nile Virus was first recognized in the 1930s in Africa and was first seen in humans in the United States in 1999 20% of people who are infected have a mild disease called West Nile fever. These patients usually experience headache, fever, and a persistent fatigue that may continue for several months. In these patients, fewer than 1% of infections develop into more serious disease, which is characterized by severe neuroinvasive illness, meningitis, encephalitis, and paralysis or poliomyelitis. West Nile Virus incubation period (i.e., from mosquito bite to onset of symptoms) is between 2 and 14 days. Currently, there is no treatment for West Nile virus infection. Medical and nursing management consists of fluid replacement, airway management, and supportive nursing care when meningitis or symptoms are present. Birds are the natural reservoir for the virus Ebola Virus Disease first human outbreak of Ebola virus disease occurred in 1976 In 2014, the virus broke this pattern and rampaged through the West African countries Liberia, Guinea, and Sierra Leone, with secondary cases in other countries in Africa, Europe, and the United States Ebola is spread through direct contact with blood or body fluids (urine, vomit, feces, saliva, sweat, semen, and breast milk) from the person who is ill from the virus and possibly from contact with semen of a man who has recovered from Ebola Ebola Virus Disease incubation period from exposure to first symptoms ranges from 2 to 21 days initial clinical manifestations include high fever, muscle aches, and fatigue third and fifth symptomatic day, the patient often develops severe diarrhea, abdominal pain, and vomiting may also show increasing neurologic symptoms during that period, such as confusion, agitation, delirium, or encephalitis. Ebola Virus Disease No therapies have been approved for Ebola Treatment is largely supportive maintenance of the circulatory and respiratory systems. Nursing management mirrors that of medical management and is largely supportive. Supportive care for a patient with such a devastating disease requires very careful use of infection control measures and psychological support for the patient and family. Legionnaires Disease is a multisystem illness that usually includes pneumonia and is caused by the gram-negative bacterium Legionella pneumophila Legionella organisms are found in many man-made and naturally occurring water sources. transmitted by the aerosolized route from an environmental source to a person’s respiratory tract Person-to-person transmission does not occur. Legionnaires Disease Risk factors for Legionella infection include diseases that lead to severe immunosuppression, such as AIDS, hematologic malignancy, end-stage kidney disease, or the use of immunosuppressive agents. incubation period ranges from 2 to 10 days. Early symptoms may include malaise, myalgias, headache, and dry cough. The patient develops increasing pulmonary symptoms, including productive cough, dyspnea, and chest pain Legionnaires Disease Diarrhea and other gastrointestinal symptoms are common. In severe cases, multiorgan involvement and failure may follow The diagnostic approach generally involves using information obtained from the history, physical examination, x-rays, laboratory findings, and assessment of therapeutic effectiveness. antibiotic agents of choice are azithromycin or a fluoroquinolone such as moxifloxacin. The antibiotic doxycycline may also be used nursing management described for the patient with any pneumonia should form the basis of care for the patient with Legionella pneumonia Pertussis also known as whooping cough, a common childhood disease in the pre-vaccine era caused by the bacterium Bordetella pertussis Highly contagious, and patients usually present to health care professionals with a paroxysmal (sudden) cough that is accompanied by a characteristic whoop—a high-pitched noise heard when inhaling. B. pertussis is transmitted by droplets Pertussis Pneumonia is the most common consequence of infection, but the disease can also lead to seizures, encephalopathy, and, rarely, death Most diagnoses of pertussis are made, at least initially, without laboratory confirmation Early treatment for pertussis is important to prevent complications. The antibiotic agents of choice are azithromycin, erythromycin, or clarithromycin Pertussis Patients who are hospitalized with pertussis should be isolated in droplet precautions until they have received 5 days of appropriate therapy. Household members should receive antimicrobial prophylaxis and should be advised to report any symptoms of an upper respiratory infection. Immunization is an important element of pertussis prevention. All adults who are around infants under 12 months on a regular basis should be vaccinated to reduce the risk of transmitting pertussis. References Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th edition, Chapter 66