NCM-112 Module: Inflammatory & Immunologic Disorders (2024) PDF

MODULE ON INFLAMMATORY RESPONSE LESSON 1 Alteration in Inflammatory and Immunologic Response LESSON 2 Inflammatory Reactio...

MODULE ON INFLAMMATORY RESPONSE LESSON 1 Alteration in Inflammatory and Immunologic Response LESSON 2 Inflammatory Reactions LESSON 3 Immunologic Reactions NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  MODULE I Alterations in Inflammatory and Immunologic Response INTRODUCTION The immune system has evolved to protect the host from a universe of pathogenic microbes that are themselves constantly evolving. The immune system also helps the host eliminate toxic or allergenic substances that enter through mucosal surfaces. Central to the immune system's ability to mobilize a response to an invading pathogen, toxin, or allergen is its ability to distinguish self from nonself. The host uses both innate and adaptive mechanisms to detect and eliminate pathogenic microbes, and both of these mechanisms include self- nonself discrimination. This overview identifies key mechanisms used by the immune system to respond to invading microbes and other exogenous threats and identifies settings in which disturbed immune function exacerbates tissue injury. OBJECTIVES After finishing this module, the students shall be able to: 1. Discuss the components and functions of the immune system and the immune response. 2. Compare antibody-mediated and cell-mediated immune response. 3. Describe the pathophysiology of wound healing, inflammation, and infection. 4. Identify factors responsible for nosocomial infections. 5. Provide teaching for clients with inflammation or an infection and their families. 6. Use the nursing process as a framework to provide individualized care to clients with inflammation and infection. DIRECTIONS/MODULE ORGANIZER 1. Read lessons and as you do, you may have with you any of the reference books to help you understand topics which need further explanation. 2. Answer the evaluation activities at the end of the lessons. 3. Consult or ask questions to a nursing instructor to further enhance the understanding of the concepts you have learned from the module. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- LESSON 1 DEFINITION OF INFLAMMATION A vascular and cellular response to trauma. Its purpose is to initiate the healing of the injured tissue. The body’s attempt to dispose of micro-organisms, foreign material and dying tissues so that tissue repair can occur. INTRODUCTION I. IMMUNE System A. Composition: Specialized cells, tissues, and organs located throughout the body including 1. White Blood Cells (WBC) 2. Thymus and bone marrow 3. Spleen, lymphoid tissues and lymph node, tonsils B. Activation: Response to some type of minor or major injury 1. Nonspecific: inflammation that prevents or limits entry of invader/injury (local) 2. Specific: immune response acts when inflammation unable to destroy organisms (systemic) D. White Blood Cells (WBC) or Leukocytes 1. Produced in bone marrow 2. Move through body via blood stream and through tissue spaces. 3. General Functions own cells from foreign cells and attach and remove foreign cells or own body’s damaged cells 4. Measurement of total WBC a. Part of Complete Blood Count (CBC) b. Normal WBC count: 4500 – 10,000/mm³ c. Leukocytosis: WBC > 10,000/mm³ d. Leucopenia: WBC < 4500/mm³ NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  5. Types of WBC A. Major groups are granulocytes, monocytes, lymphocytes B. Measurement: WBC Differential 1. Short name: “diff” 2. Count of 100 WBC sorted into different types 3. Translate into percentage (%) per type 4. Significance a) Identifies portion of total WBC made up of each specific type b) Gives assessment data as to status of immune system and its response to an injury; clues as to infection, inflammation C. Types of WBC listed in differential 1. Granulocytes: these cells are the first line of defense against microbial invasion. They are a category of WBSs composed of neutrophils, eosinophils, and basophils. a. Neutrophil (55 – 70%) total circulating leukocytes. They are phagocytic cells that recognize, ingest, and kill microorganisms Neutrophil attach to blood vessels endothelium to move through the capillary wall. This is a process called diapedesis, in which foreign particles are engulfed and trapped within the phagocytic cell. During infection, bone marrow produces and releases more neutrophils in various developmental stages. These may include, band or immature neutrophils that possess greater phagocytic activity, and segmented or mature neutrophils that possess greater phagocytic activity. b. Eosinophils (1 – 4 % total of WBC) are type of WBC that deactivates histamine and slow reactive substance of anaphylaxis (SRS-A) to decrease severity of allergic/inflammatory reactions. c. Basophils (0.5 -1% total of WBC) are cells that contain heparin, SRS – A, and eosinophil chemotactic factor of anaphylaxis. They are released as needed, such as in allergen stimulation. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  2. Monocytes (2-3%): macrophages are a large category of WBC that consists of both circulating and stationary cells. a. They are responsible for removal of antigens, damaged or old cells, and cellular debris by phagocytosis. b. They secrete substances that help with inflammatory regulation and fever. Other substances are involved in the tissue repair processes necessary for wound healing. c. Monocytes also secrete natural killer cells that have direct tumoricidal and microbicidal activity. In the lung these cells are called alveolar macrophages. In the liver they are referred to as Kupffer’s cells. The spleen and bone marrow also have cells that can assist with RBC synthesis via returning iron to transferring for transport 3. Lymphocytes (20 -40% of total circulating leukocytes): are nonphagocytic cells that function to protect the body against specific antigens. They originate from stem cells in bone marrow and differentiate into either B or T cells. There are three different types of lymphocytes which work together. 1). T lymphocytes (mature in thymus gland) 2). B Lymphocytes (mature in bone marrow) 3). NK cells (natural killer cells: immune surveillance. II. Nonspecific Inflammatory Response A. Barrier protection: body’s first line defense against infection includes a. Intact skin b. Mucus of Mucous membranes c. Bactericidal action of body fluids B. Inflammation: Nonspecific immune response 1. Nonspecific: localized, generally samewith all types of injury 2. Stages of Inflammatory response: a. Vascular response: vasodilatation leading to redness, warmth, & swelling. Three (3) types of exudates: (fluid from capillaries to tissue a) Serous (plasma) b) Sanquineous (mainly red blood cells) c) Serosanquineous (mixture) NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  b. Cellular response and pphagocytosis: margination of white blood cells to area c. Tissue repair healing: overlap of inflammation and healing 3. Cardinal signs of Inflammation: a) Redness (Rubor): Caused by blood vessel dilation (the arterioles) Chemical mediators promote the vessel dilation (contained in the capillary walls or endothelium resulting in immediate response) like histamine, seritonin , bradykinins, Prostaglandins, Note: a 1x increase in arteriole diameter yields a 4x increase in blood flow b) Swelling (tumor) Edema fluid varies with the stage of inflammation initially vessel permeability is only slightly altered and no cells or protein escapes and the fluid is mainly water and dissolved electrolytes (transudate): like synovial fluid As capillary permeability increases and plasma proteins escape the extravascular fluid becomes cloudy and more viscous. This is called exudate (contains a large amount of leukocytes (called pus) c) Pain (dolor) Results from irritation of nerve ending by physical or chemical factors Physical trauma may irritate pain receptors Chemical mediators release when cell damage occurs sensitize pain receptors Trauma may result in cell anoxia because of interference with blood flow due to capillary damage d. Warmth (calor) The result of chemical activity and increased blood flow in the injured area. E.Loss ROM May occur due to pain causing reflex guarding or muscle spasm, spasm decreases metabolic activity and constricts blood flow which causes more pain due to ischemia; thus the pain cycle NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  4. Acute or Chronic a. Acute 1. Short term, 1-2 weeks 2. Injurious agent removed 3. Healing occurs with tissue repair or scarring b. Chronic 1. Slower onset, months – years 2. Debilitating with severe tissue damage C. Wound Healing 1. Phases a. Inflammation: debridement occurs, wound prepared for healing b. Reconstruction: damage tissue regenerates 1. Resolution: original structure and function result 2. Repair: replacement of destroyed tissue by collagen scar tissue 2. Requirements a. Adequate nutrition b. Adequate blood supply c. Adequate oxygenation 3. Other Interfering Factors a. Chronic diseases, e.g., diabetes b. Drug therapies, e.g., corticosteroids c. Infection III. Immune Response A. Definition of Immunocompetent: client has immune system that identifies antigen and destroys or removes it; healthy immune response B. Characteristics of healthy immune response 1. Self-recognition 2. Specific 3. Systemic 4. Has memory (with first exposure, change in host occurs; A repeated exposure produces more rapid response) C. Types of Immune responses 1. Antibody – Mediated Immune Response (Humoral Response) a. Antigen is bacteria, bacterial toxin, or free virus b. B-lymphocyte produces antibody to specific antigen c. Immunoglobulins: antibodies produced by plasma cells.  IgG – role is to seek our infectious organisms. It is the only immunoglobulin that can cross the placenta and offer passive immunity to the newborn. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-   IgA – It is present in seromucous secretions such as saliva, tears, colostrum, breast milk, and secretions of the respiratory, GI, and reproductive tracts. It provides primary defense against local infections and prevents organisms from adhering to mucosal surfaces.  IgM – tends to remain in the blood, where it is effective against gram-negative bacteria by producing large antigen clumps that can be more easily phagocytised. It is the principle early antibody seen in the primary immune response and the main activator of the complement cascade.  IgE – binds to mast cell surfaces, where it stimulates histamine release during allergic response.  IgD – present on circulating B lymphocytes and may be involved in antigen – triggered lymphocyte differentiation. D. Actions of antibodies 1. Antibodies function in antigen neutralization or by increasing antigen susceptibility to attack by macrophages and neutrophils. This is called antibody – dependent cell – mediated cytotoxicity. 2. Antibodies make antigen more susceptible to phgocytosis by macrophages. 3. IgG and IgM can activate the complement cascade to help enhance the immune response. E. Primary and secondary immune response 1. After antigen exposure, there is a latent period in which little or no antibody can be detected in serum. 2. During this time the B cells recognizes antigen and differentiates into a plasma cell. 3. Within 4 – 10 days after the first exposure, serum antibody levels rise. IgM appears first, then IgG. 4. This is the primary immune response that is characterized by peak antibody levels followed by a rapid decrease. 5. However, memory cells that are produced are able to recall this antigen. 6. With later exposure to the same antigen, antibody is produced faster, lasts longer, and is often much higher than in the primary response. 7. Cytokine is the general term for cell-derived factors that mediate intercellular interactions. Some of these factors are called interleukins, which provide regulatory signals between various leukocytes. 8. Interferons are group of proteins secreted by various leukocytes and by infected body cells. They protect noninfected cells from viral invasion. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  Lesson 2 INTRODUCTION: INFLAMMATORY REACTION Our skin is a telltale indicator of how good you feel. Skin is the body's largest organ and has many functions, including keeping the body's inner temperatures at optimal levels, protecting the inner organs and allowing humans to have a sense of touch. When skin loses its integrity, it becomes thinner, looses its elasticity and loses its layer of fat, making it more difficult for it to do its job, notes the Victoria Australia Department of Health. Skin that loses its integrity is not just more prone to bruising, but it also heals much slower than whole, hydrated, undamaged skin.The skin is the largest sensory organ of the body, with a surface area of 15 to 20 feet and a weight of about 9 pounds. A. Functions 1. First line of defense against infections. 2. Protects underlying tissues and organs from injury. 3. Receives stimuli from the external environment; detects touch, pressure, pain, and temperature stimuli and relays that information to the nervous system. 4. Maintains normal body temperature. 5. Excretes salts, water, and organic wastes. 6. Protects the body from excessive water loss. 7. Synthesizes vitamin D3, which converts to calcitriol, for normal calcium metabolism. 8. Stores nutrients. B. Pathological Mechanisms: a.1. BACTERIAL INFECTIONS A. IMPETIGO - contagious infection of the skin caused by streptococci, staphylococci or multiple bacteria. The lesions begin as small, red macules which quickly become dicrete, thin- walled vesicles that soon rupture and become covered with a loosely adherent honey-yellow crust. PREDISPOSING FACTOR: Common among children living in poor hygienic conditions Secondary to capitis, scabies, herpes simplex, insect bites, poison ivy or eczema In adults: ill health, poor hygiene and malnutrition. Bullous impetigo- superficial infection of the skin caused by S. aureus, is characterized by the formation of bullae from original vesicles. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- MANAGEMENT: 1. Systemic antibiotic therapy: Benzathine penicillin or oral penicillin ( nonbullous impetigo) Cloxacillin, Dicloxacillin (Bullous impetigo) Antiseptic preparation: Povidone-iodine (Betadine); Chlorhexidine (Hibiclens) Topical medication: Neomycin, Bacitracin ( after lesions are washed with soap and water) 2. Practice good hygienic practices: Separate towel and wash cloth Bathe at least once daily with bactericidal soap B. FOLLICULITIS Staphylococcal infections that arises within the hair follicles. Lesions may be superficial or deep. Single or multiple papules or pustules appear close to the hair follicles. Commonly seen in the beard area of men who shave and on women’s legs. Also include the axillae, trunk and buttocks. - Pseudofolliculitis barbae (shaving bumps)- an inflammatory reaction on the face of curly-haired males caused by ingrowing hairs that pierce the skin and cause an irritative reaction. a) FURUNCLE start as a small, red, raised painful “pimple”. Infection progresses and involves the skin and subcutaneous fatty tissue, causing tenderness, pain and surrounding cellulitis. There is a characteristic pointing of a boil produced by the necrosis of invading tissues then the center becomes yellow or black. b) CARBUNCLE - abscess of the skin and subcutaneous tissue representing an extension of a furuncle that has invaded several follicles and is larger and is more deep- seated. The back of the neck and the buttocks are the common sites. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  MANAGEMENT OF FOLLICULAR DISORDERS  The boil or pimple should never be squeezed.  Systemic antibiotic therapy: Oral cloxacillin, dicloxacillin and flucloxacillin (first-line drug therapy); Cephalosporins and erythromycin.  Intravenous fluids, warm moist compresses, antibacterial soap and ointment.  A small incision will relieve the tension and ensure a direct evacuation of the pus and slough.  Keep draining lesion covered with a dressing. Universal and Isolation precautions should be observed.  Special precautions must be taken with boils on the face  Bed rest is advised to patients with boils in the perineum and anal region  Prevention of recurrent infections include a daily dose of oral Clindamycin continuously for 3 months.  Increase the patients resistance and provide a hygienic environment. a.2 Pemphigus Vulgaris Definition: A serious autoimmune disease of the skin and of the mucous membranes, characterized by the appearance of blisters of various sizes on apparently normal skin and mucous (mouth, esophagus, conjunctiva,vagina). Etiology: The cause is unknown, certain drugs, other autoimmune diseases, and genetics may play a role in its development. Manifestation Initial lesions may appear in oral cavity appearing as irregularly shaped erosions that are painful, bleed easily and heal slowly Bullae may arise on normal or erythematous skin, enlarge, rupture and leave large painful eroded areas that are accompanied by crusting and oozing. An offensive odor may emanate from the bullae when it ruptures, it will heal slowly and eventually widespread areas of the body may become involved. Positive NIKOLSKY’S SIGN – separation of the dermis when minimal pressure is applied to the skin; blistering and sloughing of uninvolved skin. Erode skin heals slowly and bacterial superinfection is common. Management Corticosteroids in large doses to control the disease and keep the skin free of blisters. Should have daily evaluations of body weight, BP, blood sugar and recording of fluid balance. Immunosuppressive agents such as cyclophosphamide (cytoxan), and azathioprine (Imuran), Gold are used alone or in combination with steroids. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  Long term administration of immunosuppressive drugs is associated with numerous side effects and risks; hyperglycemia, osteoporosis, psychosis, adrenal suppression, and increased risk of cancer. Plasmapheresis- temporarily decreases the serum level of antibodies with variable success. a.3 Infestations and Parasitic A. Scabies: caused by a mite, called Sarcoptes scabiei. Found in people living in substandard living condition. Spread thru direct physical contact. Clinical Manifestations: Severe pruritic, small, raised burrows. May be red or brown threadlike lesions Most common sites: between fingers, wrists, extensor surfaces of elbows, around nipples, axillary folds, groin. Medical Management: Take warm, soapy bath or shower to remove the scaling debris from the crusts. Lindane (Kwell) – can cause neurotoxicity; not safe for infants, pregnant women or in any patient with wide spread excoriations and open skin. Crotamiton (Eurax), Permethrin 5% cream- highly effective and safe, Oral antihistamines: help control itching. Nursing Implementation: Treat all family members, Procedure for Lindane (Kwell): 1) Apply a thin layer over the entire body from neck down 2) Wash off in 8-12 hours 3) give a second treatment in 24 hours if prescribed. Wash underclothing and bed and bath linens in hot water on the day of treatment; dry in dryer or iron after dry; change linens daily. B. Pediculosis – caused by Pediculus humanus louse Types: a)PEDICULOSIS CAPITIS Infestation of the scalp by the head louse, Pediculus humanus capitis. The eggs are visible to the naked eye as silvery, glistening oval bodies that are difficult to remove from the hair. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  SIGNS AND SYMPTOMS:  Intense itching  Scratching that leads to pustules, crusts, matted hair, impetigo and furunculosis TRANSMISSION:  Direct physical contact  Indirectly through the use of infested combs, brushes, wigs, hats, bedding MANAGEMENT:  Shampoo with Lindane (Kwell) or pyrethrin compounds with piperonyl butoxide.  Articles that might have lice should be washed in hot water or dry-cleaned  All family members and close contacts are treated. Antipruritics, systemic antibiotics and topical corticosteroids for severe pruritus, pyoderma and dermatitis B. PEDICULOSIS CORPORIS - Infestation of the body by body louse, Pediculus humanus corporis. It lives chiefly in the seams of underwear and clothing. C. PEDICULOSIS PUBIS – crab louse (Pthirus Pubis) – genital region SIGNS AND SYMPTOMS:  Hemorrhagic points  Widespread excoriation  Secondary lesions: parallel linear scratch and a slight degree of eczema  Skin is thickened, dry and scaly with dark pigmented areas COMPLICATIONS:  Severe pruritus, pyoderma (pus-forming infection of the skin) and dermatitis.  Rickettsial disease (epidemic typhus, relapsing fever and trench fever) NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  MANAGEMENT:  Instruct to bathe with soap and water  Lindane (Kwell) or malathion in Isopropyl alcohol (Prioderm lotion) is applied to the affected area  Alternative topical therapy is a pyrethrin-based pediculicide or.03% copper oleate (Cuprex)  All clothing and bedding should be machine-washed or dry-cleaned a.4 Vaccine - Preventable Infectious Disease A. POLIOMYELITIS (infantile Paralysis). It attacks the brain stem and spinal cord. Etiology: Virus. The disease is caused by any one of 3 polioviruses: a. Type 1 (Brunhilde). b. Type 2 (Lansing). c. Type 3 (Leon). Incubational Period: 5-14 days. Communicability Period: Latter period of incubational period till the first week of acute illness. Mode of Transmission: Oral contamination by intestinal and pharyngeal secretions of infected person. Predisposing Factors: Fatigue and muscle exertions, Cortisone administration, Tonsillectomy and adenoidectomy, Tooth extraction. I.M injection of D.P.T. vaccine. Nursing Assessment: Severity of nerve involvement can vary from an absence of all clinical signs of paralysis to complete paralysis. There are different possible consequences of infection: 1. Inapparent poliomyelitis: (Silent) No signs or symptoms appears. 2. Abortive poliomyelitis: Initial symptoms of upper respiratory tract infection: fever, headache, vomiting…etc. 3. Non-Paralytic Poliomyelitis. Problems as those of Aseptic Meningitis Syndrome. Stiffness of neck, back and limbs, Nausea and vomiting become more severe than stage II, Fever, Increase protein in C.S.F. 4. Paralytic Poliomyelitis: This may begin with manifestations of the abortive or non-paralytic type. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  a. Spinal: paralysis appear within a day or two after the above manifestations and 2-5 days from onset of the disease: - Paralysis of limbs is the most common affected muscles - Muscles of the chest, abdominal wall, diaphragm, urinary bladder and bowel can be affected constipation or stool incontinent and urinary incontinent may occur. b. Bulbar: More life threatening. It causes damage to cranial nerve nuclei, vital centers of respiration, circulation and temperature control. It may leads to swallowing problem and regurgitation of fluids from nose and inability to swallow saliva, which puddles in the pharynx. If not aspirated chocking may occur. C. Encephalitis: Manifesting as encephalitis, only diagnosed as polio encephalitis if spinal or bulbar affections or both are present, convulsion, personality disturbances. Nursing Considerations: 1. Isolation and bed rest. 2. In acute stage:  Put the child under close observation.  Notify the doctor about the degree and progress of the paralysis (7 or 8 days of the disease).  Rate and type of respiration and signs of respiratory distress must be observed and reported.  Oxygen therapy or place the child on respirator when cyanosis occurs.  If tracheostomy is done in case of diaphragmatic paralysis, care of tracheostomy. 3. For paralysis:  Change position frequently. Careful positioning for affected limbs each time he is turned or moved.  To minimize the degree of deformity, correct body alignment and optimum position must be maintained.  Place the child on firm mattress.  Use footboard to prevent foot drop when child is on back. If the child is on abdomen, pull the mattress away from foot of bed and letting feet protrude over the edge to prevent pressure on toes.  Application of heat to affected muscles to relax them.  Suction of the pharynx and postural drainage to prevent aspiration of secretions.  For swallowing difficulties: NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-   Soft diet if they can swallow with difficulty.  If swallowing is difficult, use gavage feeding.  For incontinent:  Skin care and perineal region is padded to provide absorption for excretions. Catheter may be done.  For constipation: Use enemas.  Treat fever and headache. Prevention: Active immunization: Trivalent poliovirus vaccine. (TOPV).  Sabine: Attenuated virus, which is administered orally.  Salk: Killed virus, which is administered by injection. Note: If a child is affected by poliomyelitis, he must receive the vaccine to prevent further infection from the other poliovirus types.  Passive immunization: Gamma- globulin. B. TETANUS (Lock Jaw) Etiology: Clostridium tetanti (tetanus bacillus). Incubational Period: 3-21 days. Communicability Period: Not communicable from man to man, as the organisms usually live in animal’s intestinal tract. Mode of Transmission: Through a wound as organism is present in soil. Nursing Assessment: Onset of the disease is either gradual or acute. 1. Convulsions are the first warning symptoms in children. 2. Excessive irritability and restlessness. 3. Difficulty in swallowing. 4. Stiff neck. 5. Within 24-48 hours, the muscular stiffness progress: ◦ Trismus i.e. tight jaw, inability to open the mouth. ◦ Stiff arm and legs, then entire stiffness of the body. ◦ Swallowing usually becomes impossible. ◦ Resus sardonicus due to spasm of facial muscles. ◦ Opisthotonos, i.e., backward arching of the back as a result of the dominance of the extensor muscles of the spine, head draws back. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  ◦ This ongoing tetanic spasm lasts about 10 seconds and occurs following slightest stimuli, such as, clamming the door or bumping the bed. 6. Dyspnea and cyanosis can develop. 7. Fever 38.5 -40°C. 8. Constipation may develop. 9. Lumbar puncture reveals increase reveals increase spinal fluid pressure. Nursing Consideration: 1. Isolation. 2. Protect the child from any stimuli (auditory or tactile stimuli), so place the child in dark, quite room and minimum handling. 3. If dyspnea and cyanosis are present, give oxygen. 4. For tetanic spasm: ◦ Protect the child from falling. ◦ The nurse must be alert for number, duration and frequency of convulsion (in relation to sedation administered). ◦ Record any change in trismus or inability to swallow. 5. For inability to swallow: ◦ I.V. therapy for nutrition and fluid balance. ◦ Gavage feeding may be ordered. So, the nurse must report if insertion of the tube causes convulsions. ◦ Accurate intake and output chart is necessary. ◦ Mouth care if he can open his mouth. 6. For constipation, give enema. 7. Check vital signs carefully. 8. If tracheostomy is performed; care of tracheostomy. 9. Naso-pharyngeal suction is done frequently. Treatment: a. Antibiotics (Penicillin). b. Antitoxin. c. Tranquilizers. Prevention: 1. Active immunization: DPT vaccine. 2. Passive immunization: Injection of tetanus immuno-globulin or antitoxin (a few hours after a wound occur). Complication: 1. Anoxia. 2. Atelectasis. 3. Pneumonia. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- C. DIPTHERIA Etiology: Corynebacterium diphtheria (Diphtheria bacillus). Incubational Period: 2-5 days or longer. Communicability Period: Several hours before onset of the disease until organism disappear from the respiratory tract. Mode of Transmission: Droplet from respiratory tract of an infected person or a carrier directly or indirectly. Nursing Assessment: A child with diphtheria usually seeks medical help for one of the following complains (sometimes they are called types). 1. Sore throat: ◦ Fever. ◦ Difficulty to swallow. ◦ Swelling of the neck. ◦ Exudates or a yellow-gray membrane on tonsils and may be the pharynx. (Membrane varies from thin to thick one). 2. Croup: ◦ Hoarse or croupy cough and stridor. ◦ Noisy respiration, the child may have severe ◦ respiratory distress. ◦ The membrane may cover the vocal cord (When examined with laryngoscope). 3. Nasal discharge: ◦ Purulent, bloody nasal discharge. ◦ Membrane can be seen on the nasal septum. 4. Infected skin ulcer: ◦ This skin ulcer can be confused with ◦ impetigo (skin disease). The membrane is not always present in diphtheria. 5. Other signs and symptoms: That could be present (especially in severe cases): ◦ Purulent conjunctivitis. ◦ Otitis media. ◦ Ulcerative vulvo-vaginitis. ◦ A toxin from organisms produces fever and malaise. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- Nursing Consideration: 1. Isolate the child (place him in isolating room, use medical aseptic techniques). Keep the child in isolation until 2 consecutive nose and throat culture are negative (24 hours apart between the two cultures). 2. Bed rest for about 6 weeks for all types except in nasal diphtheria. 3. For respiratory distress (if present): suction to trachea and larynx to remove secretions and pieces of membrane, oxygen humidifier. 4. For fever: check vital signs, use 2-3-4 hours schedule; depending on the degree of fever, degree of respiratory embarrassment and change in pulse rate. Check blood pressure frequently. 5. For the membrane: Oral hygiene (warm mouth wash, never use tooth brush or swabs because of danger of distracting the membrane leading to bleeding and rapid spread of toxins into blood system. 6. Observe: vital signs, secretion and the need for suction, observe signs and symptoms of paralysis. 7. Tracheostomy and /or intubation trays must be ready at bedside table of the child. If tracheostomy or intubation is done, apply the proper care of tracheostomy or intubation. ◦ In intubation, the child can expel the tube when he coughs, so watch constantly as he can’t call for help. Frequent suctioning of the tube use proper restraints so that he will not remove the tube. 8. If myocarditis appears as a complication, guard the child for exhaustion, beside the other nursing care. Treatment:  Bed rest.  Antibiotics.  Anti-toxins Prevention: 1. Active immunization: DPT vaccine. 2. Passive immunization: injection with anti-toxins. Complications ◦ Bronchopneumonia. ◦ Kidney dysfunction. ◦ Paralysis. ◦ Myocarditis. ◦ Cardiac failure. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- D. PERTUSSIS (Whooping Cough) Etiology: Gram-negative bacillus. Incubation Period: 5-14 days. Communicability Period: 4-6 weeks from the onset of the disease. Mode of Transmission: Droplet (direct and indirect). Nursing Assessment: Three stages: a. Catarrhal stage:(coryza or prodromal stage) It lasts 7-14 days. Mild fever, headache, anorexia, sneezing, persistent cough with tearing. b. Paroxysmal stage (Spasmodic or whooping stage): Lasts 14-28 days (2-4 weeks). ◦ Paroxysmal cough develops. It is characterized by several sharp coughs in one expiration, followed by one deep inspiration, which may be accompanied by a whoop. Cough is worse at night, interferes with sleep and frequently causes vomiting. ◦ With cough, face becomes flushed and in some instances cyanosis and dyspnea might occur. ◦ Anorexia. ◦ Lymphocytosis occurs. c- Convalescent stage: It lasts 21 days. ◦ Cough and vomiting become less. Nursing Consideration: 1. Isolation: Disinfection all utensils. 2. Bed rest: keep the child in bed in a well ventilated room. 3. For paroxysmal stage: Provide; ◦ atmosphere to avoid emotional swings as laugh and cry causing coughing attacks. ◦ Avoid dust in the room. ◦ Oxygen with humidity to relief cyanosis (may use oxygen tent). 4. For vomiting: ◦ Raise head and shoulders of older children to ◦ avoid aspiration of vomitus. For young children, place them on abdomen if no one is attending in the room. ◦ Mouth care. ◦ Small frequent feeding. Refeed the child after vomiting. ◦ Accurate intake and output must be kept. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  5. For anorexia: ◦ High caloric soft diet. Encourage the child to eat. ◦ Weight the child daily. 6. If anoxia occurs during paroxysms a tracheo-pharyngeal suction may be needed. So keep the suction machine available. 7. Protect the child from secondary infection, keep him warm. 8. Observe: respiratory distress and convulsions. 9. Observe signs and symptoms of airway obstruction e.g. restlessness, cyanosis, retraction. Treatment: ◦ Symptomatic: sedatives and antispasmodics are important. ◦ Antibiotics are effective if given early (Ampicillin and Erythromycin). Prevention: 1. Active immunization: DPT vaccine. 2. Passive immunization: Gamma Globulin. 3. In exposed immunized children, give an immediate booster dose of pertussis vaccine. Complication: ◦ Otitis media. ◦ Bronchiectasis. ◦ Hemorrhage may occur. ◦ Marasmus. ◦ Encephalitis. ◦ Pneumonia. E. MUMPS (Infectious Parotitis) Mumps is common in children 5- 10 years. It is acute virus infectious disease, which may involve, many organs but commonly affects the salivary glands (mainly parotids glands). Etiology: Paramyxovirus Virus. Incubational Period: 14-21 days. Communicability Period: One to six days before the first symptoms appears until the swelling disappears. Mode of Transmission: Direct or indirect contact with salivary secretion of infected person. Nursing Assessment  Low-grade fever.  Vomiting. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-   Headache.  Malaise and anorexia. Acute Phase: 1. Pain in or behind ears and pain on swallowing or chewing. 2. Swelling and pain in glands (unilateral or bilateral), which return to normal in 10 days. 3. Orchitis in males and mastitis in female adolescent may occur. Nursing Consideration: 1. Isolation. 2. Bed rest until swelling disappears. 3. For fever: Encourage fluids and soft food, avoid food required chewing, and tipped compresses, antipyretics. 4. For glands: ◦ Mouth care and gargle frequently. ◦ Apply hot or cold compresses for the swelling. Use ice bag (watch weight of the bag in order not to increase the pain). 5. For Orchitis: Support scrotum, use cold compresses for 20 minutes, then, remove it for 30 minutes, then, reapply it for 20 minutes…etc. 6. For Mastitis: Breast support, use cold compresses. Treatment: ◦ Symptomatic. ◦ Sedatives. Prevention:  Active immunization: Live attenuated vaccine.  Passive immunization: Gamma- globulin. Complication: (rare) ◦ Sterility ◦ Ovaritis ◦ inflammation of testicles ◦ Deafness. F. MEASLES (Rubeola) Most cases occur before adolescent and it occurs more in spring months. Etiology: Paramyxoviridae Virus Incubational Period: 7-14 days (usually 10-20 days). Communicability Period: 4 days before the appearance of rash to 5days after rash appearance. Mode of Transmission: Droplet (direct or indirect). Nursing Assessment: NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  1. Coryza: Primary symptoms which resembles common cold and occur before rash appearance:  Sneezing. ◦ Fever (range from 38.5 to 40°C, tending to be highest just before the appearance of rash). ◦ Brassy or barking cough. ◦ On the 4th day, conjunctivitis and photophobia. ◦ Acute catarrhal inflammation of the mucous membrane of the nose. ◦ Enlarged posterior cervical lymph nodes. 2. Koplik’s Spots: Are pathogenic appear on day before rash. Whitish spots resting on a reddish base appear on the inside of the mouth. They can appear and disappear suddenly. 3. Rash: Rash appears on 2nd to 5th day and remain about a week.  Appears first on face, behind the ears, on the neck, forehead or cheeks. Then, spread downwards over the rest of the body (trunk, arms, and legs).  The rash is pinkish in color, begins with macular lesions which progress to the popular type. Then, rash becomes dark in color (brownish color on 5th day).  Desquamation, which is fine usually, follow the rash appearance and then fads (disappear).  Rash is itchy. Nursing Consideration: 1. Isolation. 2. Bed rest: Occupy the child in bed after acute phase with activities. Explain the reason for being in bed if the child is old enough to understand. 3. For photophobia and conjunctivitis: ◦ Subduced light make the child more comfortable. ”Dark room”. ◦ Eye care with warm saline solution to remove secretions or crust. ◦ Keep child’s hands away from eyes, examine coma for signs and symptoms of ulceration. 4. For fever: ◦ Measure the temperature carefully. ◦ Antipyretic as doctor’s order. ◦ Encourage fluids. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  ◦ Tipped compresses. 5. For itchy rash: Observe degree of itching and apply lotion or ointment as doctor’s order. 6. For Koplik’s spots: Mouth care. Use gargle solution. 7. Carry out the plan of care of complicated cases, such as, encephalitis (convulsions), dyspnea…. etc. Treatment: ◦ Symptomatic. ◦ Antibacterial therapy. Prevention:  Active immunization: live attenuated vaccine.  Passive immunization:  Newborn through the mothers while they were in uterus. *Gamma-globulin. Complication ◦ Otitis media, Tracheobronchitis, Imptiago, purpura, Lymphoadenitis, Pneumonia, Encephalitis. GERMAN MEASLES (Rubella)  It is not as communicable as measles. Fetus may contact the disease in uterus if the mother develops the disease during the pregnancy (1st trimester).  Etiology: Rubella Virus ( Togaviridae, genus: Rubivirus)  Incubation Period: 14 to 21 days.  Communicable Period: During prodromal period and for 5 days after the rash. Mode of Transmission: 1. Direct contact with nose and throat secretions of infected persons. 2. Indirect via articles freshly contaminated with nasopharyngeal secretion. 3. Trans-placenta congenital infection form infected mother to the fetus. Nursing Assessment: Prodromal Stage: ◦ Mild fever (Disappear when rash appear). NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  ◦ Slight malaise, headache, and anorexia. ◦ Running nose, sore throat. ◦ Rash is faint macular rash. It is small pinpoint pink or pale red macules which are closely grouped to look like scarlet blush (botchy), which fades on pressure. “It begins on face and hairline move to trunk then extremities”. Rash disappears in 3 days. ◦ Swelling of posterior cervical and occipital lymph nodes. ◦ No Koplik’s spots or photophobia. Nursing Consideration 1. Isolation especially form pregnant women. 2. Bed rest until fever subsided. Treatment: ◦ Symptomatic. Prevention: a- Active immunization; live attenuated rubella virus vaccine. b- Passive immunization: Gamma- globulin. Complication: ◦ Fetus damage if mother contacts the disease during pregnancy. ◦ Newborn may have congenital anomalies, such as deafness, mirocephaly, mental retardation. ◦ Encephalitis. G. CHICKEN POX (Varicella) Etiology: Virus [Varicella- Zoster- Virus (VZV)]. Incubational Period: 10-21 days (2-3 weeks). Communicability Period: One day before and six days after the appearance of the first vesicle. Mode of Transmission: Droplet (direct or indirect). Dry scabs are not infectious. Nursing Assessment:  Onset is sudden with: Prodromal Stage: ◦ Mild or light fever. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  ◦ Anorexia. ◦ Headache. Acute Phase:  Rash: Successive crops of macules, papules, vesicles, crusts (vesicles heals by forming the crusts by the end of the two weeks). (Acute Phase).  Rash appears in successive crops and lesions in all stages of development at the same time. Rash is itchy. Nursing Consideration: 1. Isolation: ◦ Use medical aseptic technique. ◦ Nasal and oral discharge, cloths and linens are currently disinfected. ◦ Keep the child in isolation until all crusts disappear. 2. For rash (lesion): ◦ Cleaning the skin according to doctor’s order once or twice daily. Cool sponge bath without soap. ◦ Change child’s clothes and bed linens daily to prevent skin infection. ◦ For itchy lesions, nails must be cut and cleaned. Mittens and gloves to prevent skin scratching. ◦ Restraints may be needed to control scratching. ◦ Observe the skin lesions, change in appearance and it must be recorded. ◦ If lesions in mouth, mouth wash. ◦ If lesions in genital organ, apply cold compresses. 3. For fever: ◦ Check vital signs and record it, especially temperature. ◦ Keep records for the first 7 days of the disease. 4. If secondary infection to skin occurs: intake and output chart must be kept accurate. 5. Observe for complications and report immediately to the doctor. Treatment: ◦ No specific treatment. ◦ To relieve itching, calamine lotion, antihistamine and local aneaesthetaic ointment are prescribed. ◦ Antibiotics for secondary infection. ◦ Don’t give aspirin due to high risk of Reye syndrome. Prevention: None NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- Complication: ◦ Abscess, Encephalitis, Glomerulonephritis may occur. H. HEPATITIS:  Hepatitis A. (infectious hepa)  Hepatitis B (Serum Hepa)  Hepatitis C. (post transfusion hepa)  Hepatitis D (Dormant type) Causative Agent (CA): Hepa A Virus ◦ `Mode of Transmission (MOT): Fecal Oral ◦ Incubation period: 2-7 weeks Hepatitis B ◦ CA: Hepa B Virus ◦ MOT: percutaneous Transmission Through punctures, Sexual Transmission, oral transmission through prenatal transmission ◦ Incubation Period: 6 weeks to 6 months ◦ Person at risk: Drug addicts, nurses hemodialyzing patient, blood recipients’, promiscuous Individual Hepatitis C ◦ CA: Hepa C Virus ◦ MOT: percutaneous transmission particularly BT ◦ At risk: blood recipients’, health careworkers ◦ Incubation period: 2 weeks to 6 months Hepatitis D ◦ CA: Hepa D Virus ◦ MOT: Same as hepa B ◦ Incubation period 2 weeks to 6 months Hepatitis E ◦ CA: Hepa E virus ◦ MOT: Fecal-oral ◦ Incubation Period: 2-6 mos. Manifestation: 1. pre-icteric stage  RUQ pain  weight loss, fatigability, body malaise  presence of fever  anemia 2. icteric stage NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-   juandice, pruritus  acholic stool  hepatomegally, splenomegally 3. post-icteric stage road to recovery Diagnostic exam: ◦ Liver function test – test to determine the extent of the liver damage ◦ Serum test ◦ Bilirubin testing ◦ Ultrasound of the liver Medical Management: ◦ Symptomatic treatment Nursing Management: ◦ CBR ◦ Nutrition ◦ Skin care ◦ psychological Support ◦ I. INFLUENZA VIRUS Influenza, commonly known as “the flu”, is a highly contagious infection of the airways caused by influenza viruses. A, B and C influenza viruses Influenza A and B viruses cause seasonal epidemics, while type C viruses cause mild respiratory illness Influenza A viruses are classified into different strains or subtypes based on two proteins or antigens on the virus surface: hemagglutinin (H) and neuraminidase (N) – e.g., H1N1 and H3N2 Influenza B viruses can be classified into two antigenically distinct lineages, Yamagata and Victoria like viruses Influenza A and B strains are included in each year's influenza vaccine The vaccine does not protect against influenza C viruses CAUSE: RNA Virus The influenza virus, commonly known as the flu, is an infectious disease of birds and mammals caused by RNA viruses. Commonly confused with a cold, the flu is a much more severe disease and caused by a different virus. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- Influenza Types – A and B Type A (Seasonal, Avian, Swine Type B (Seasonal influenza) influenza) Can cause significant disease Generally causes milder disease but may also cause severe disease Infects humans and other species (e.g. Limited to humans birds; H5N1) Can cause epidemics and pandemics Generally causes milder epidemics (worldwide epidemics) How strains change each year Small changes in influenza viruses occur continually – New virus strains may not be recognized by the body's immune system A person infected with a specific influenza virus strain develops antibodies against that specific strain In most years, some or all of the three virus strains in the influenza vaccine are updated to align with the changes in the circulating influenza viruses Annual influenza immunization is recommended to protect against infection from these changing influenza viruses Signs and symptoms of influenza Sudden onset Typically starts with a headache, chills and cough, followed rapidly by fever, loss of appetite, muscle aches and fatigue, runny nose, sneezing, watery eyes and throat irritation Nausea, vomiting and diarrhea may also occur, especially in children Influenza incubation Individuals with influenza are infectious 1 day before symptoms develop and up to 5 days after becoming ill – The period when an infected person is contagious depends on the age and health of the person – Young children and people with weakened immune systems may be contagious for longer than a week The time period from exposure to development of symptoms is about 1 to 4 days, with an average of about 2 days. Treatment of influenza Treatment recommendations for non-complicated cases include: rest. Analgesics, fluids, time NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- Prevention & Treatment: 1. Get the flu vaccine each year due to high mutation rate of the virus. 2. Practice good hygiene and personal health habits 3. Cover your mouth when while sneezing and wash your hands regularly as the virus spreads through aerosols. 4. Since the flu is a virus, antibiotics won’t work unless there is a secondary bacterial infection. a.5 Others A) Acquired Immunodeficiency Syndrome Acquired immunodeficiency syndrome (AIDS) is the final result of an infection with a retrovirus, the human immunodeficiency virus (HIV). AIDS is a disease rather than a syndrome, which is a term used to refer to collections of symptoms that do not have an easily identifiable cause. This name was more appropriate in the early years of the AIDS epidemic, when healthcare providers were aware only of the late stages of the disease and did not fully understand its mechanisms. The more current name for the condition is HIV disease, which refers to the pathogen that causes AIDS and encompasses all the phases of the disease, from infection to the deterioration of the immune system. AIDS is still the name that most people use to refer to the immune deficiency caused by HIV. The Centers for Disease Control and Prevention (CDC) first described AIDS in 1981, and since then the disease has become one of the most widely publicized and feared diseases of our time. Experts suggest that more than 1 million Americans and 40 million people worldwide are infected with HIV. More than 95% of those people infected are in developing nations. The CDC proposed a four-stage classification for the phases of HIV infection. Proposed CDC Four-Stage Classification for the Phases of HIV Infection Classification Description Comments Group I Acute infection Early, acute phase in an immunocompetent person to an HIV infection. Widespread level of viral production occurs with widespread seeding of lymph tissues. Symptoms are generally nonspecific, such as sore throat, myalgia, fever, weight loss, and fatigue. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  Symptoms occur 3–6 weeks after infection and resolve 2–4 weeks later Group II Asymptomatic infection In the middle phases of disease, patients may remain asymptomatic (Group II) or may develop a persistent generalized lymphadenopathy. In either case, HIV replication occurs primarily in the lymphoid tissues. Group III Persistent generalized Patients may remain in lymphadenopathy Group II or Group III, which are middle, chronic phases. Patients may also experience opportunistic infections such as herpes zoster and candida. Most but not all people progress to AIDS in 7–10 years. Group IV Final crisis phase with Final crisis phase constitutional characterized by a disease, neurological breakdown of immune disease, secondary defenses, increased viral infection or neoplasm, or counts, and multiple other conditions clinical signs such as persistent fever, fatigue, weight loss, diarrhea, and serious opportunistic infections (protozoal, helminthic, fungal, bacterial, viral) and neoplasms such as Kaposi’s sarcoma and primary lymphoma of the brain. HIV infection of lymphocytes and other cells that bear specific protein markers leads to lymphopenia and impaired T and B cell function. When HIV infection becomes advanced it often is referred to as AIDS, which generally occurs when the CD4 count is below 200/mL. AIDS is characterized by the appearance of opportunistic infections. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- CAUSES HIV causes AIDS. Two HIV strains have been identified: HIV-1 and HIV-2. HIV-1 is the prototype virus and is responsible for most cases of AIDS in the United States. HIV-2 is found chiefly in West Africa, appears to be less easily transmitted, and has a longer incubation period. Susceptibility to infection is unclear. The presence of sexually transmitted infections (STIs) with open lesions, such as herpes and syphilis, may increase the patient’s susceptibility to viral entry. People with cytomegalovirus and Epstein-Barr virus infections may also be more susceptible because of an increased number of target cells. Routes of transmission are through sexual contact (male to male, male to female, female to male, and female to female); by blood to blood or transfusion contact (generally blood products given between 1977 and 1985); through the use of needles contaminated by an HIV-infected person; by blood or other HIV-infected fluids coming in contact with open lesions or mucous membranes; and by mother to child during the in utero period, during delivery, or by breastfeeding. The time from the onset of HIV transmission to the development of AIDS varies from a few months to years. The median incubation period is 10 years. High-risk behaviors that are linked to HIV infection include unprotected anal and vaginal intercourse, having multiple sex partners, and using nonsterile drug injection equipment. GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS The patterns of HIV-related deaths have changed during the past 5 years. In the late 1990s, HIV was the second leading cause of death in the United States in men ages 25 to 44 years and the third leading cause of death in women of the same age range. Recent statistics show that HIV related deaths remain 1 of the top 10 causes of death in both men and women 20 to 54 years of age, with the highest number of deaths for men (approximately 4000/year) and women (approximately 1500) occurring during 35 to 44 years of age. Black/African Americans bear a disproportionate burden of HIV disease compared with other populations. In addition, 68% of women with newly diagnosed HIV disease are black/African American, and many of those women live in the southern parts of the United States. Individuals can contract HIV at any time during their life span, including infancy. The average time between exposure and diagnosis in adults is from 8 to 10 years, although the incubation period varies among people. In children, the incubation period is approximately 18 months. Children are likely to have a history of repeated bacterial infections such as middle ear infections and pneumonia. Most of the AIDS cases in children are the result of maternal-child transmission. ASSESSMENT HISTORY. Common symptoms include night sweats, lymphadenopathy, fever, weight loss, fatigue, and rash. Gastrointestinal (GI) disturbances such as nausea, vomiting, diarrhea, and anorexia are common. The patient may describe NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- neurological manifestations, including headache, lightheadedness, memory loss, word-finding difficulty, inability to concentrate, and mood swings. Patients may notice gait disturbance, a “stiff” neck and pain, burning, numbness, and tingling in the extremities. A history of infections such as tuberculosis, herpes, hepatitis B, fungal infections, or STIs is common in the HIV and AIDS population. PHYSICAL EXAMINATION. Patients with HIV and AIDS are at risk for opportunistic infections that affect all systems and diseases common to their age group (Box 1). Wasting syndrome is common to AIDS patients. Fever may or may not be present. The patient’s skin may have a generalized rash or lesions from herpes or Kaposi’s sarcoma (a metastasizing skin cancer). Ask the patient to walk during the examination to examine the patient’s gait. Note ataxia, motor weakness, gait disturbance, and hemiparesis. Palpate the patient’s lymph nodes to determine if lymphadenopathy is present, particularly in two or more extrainguinal sites. Symptoms in AIDS Patients Requiring Medical Attention New cough Shortness of breath or dyspnea on exertion Increased fatigue or malaise Fever Night sweats Headache or stiff neck Visual changes: Floaters, blurring, photophobia, changes in visual fields Mental status alteration: Change in level of consciousness, loss of memory, forgetfulness, loss of concentration, depression, mood swings New onset of diarrhea Sudden weight loss Increased size of or pain in lymph nodes Skin lesions PSYCHOSOCIAL. Diagnosis of HIV is a crisis, and the crisis may exacerbate any underlying psychiatric disorders. A person may be in a state of denial or have anxiety, psychological numbness, depression, or suicidal ideation. Remember that, in this state, people cannot focus and do not hear what healthcare professionals tell them. The patient undergoes a fear of the loss of sex life, contaminating others, rejection, and stigma. Fears about loss of employment, financial independence, and insurance are realities. As the disease progresses, grief over losses, hopelessness, suicidal ideation, and emotional exhaustion may occur. The patient deals with stress over the demands of treatment, embarrassment because of physical symptoms, and loneliness. NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- Diagnostic Highlights Test Normal Result Abnormality with Explanation Condition Enzyme-linked Negative for HIV Positive for HIV Positive ELISA immunosorbent antibodies antibodies test is assay (ELISA) and confirmed by a Western blot Western blot T lymphocyte and B cells: B and T cell HIV infects cells B 65–4785/mL; values decreased. with lymphocyte CD4 T cells: CD4 counts less the CD4 protein subsets; 450–1400/mL; than 500/mL are marker CD4 counts, CD4 CD4 to CD8 T generally percentages cell ratio: 1:3.5 associated with symptoms; CD4 counts less than 200/mL are associated with severe immune suppression. Any HIV infected person with a CD4 level less than 200/mL is considered to Viral load: Negative Detects number Quantitative polymerase chain of copies/mL; test assay reaction (PCR) has a lower limit that measures of 400 copies/mL amount but can of HIV-1 RNA in reach levels at plasma 30,000 copies/mL and higher; ultrasensitive assay has a lower limit of 40 copies/mL NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- PLANNING AND IMPLEMENTATION Collaborative Much of the collaborative management is based on pharmacologic therapy (see below). Supportive management consists of treatment of malignancies with chemotherapy and irradiation, treatment of infections as they develop, and the management of discomfort with analgesia. Surgical management may be needed to excise lesions from Kaposi’s sarcoma or to drain abscesses. If the patient becomes short of breath, oxygen is often prescribed to improve gas exchange. Dietary support is important I the treatment of HIV infection and AIDS throughout the progression of the illness. Pharmacologic Highlights Antiretroviral therapies are grouped into four categories and should always be used in combination. Introduction of highly active antiretroviral therapy (HAART) is capable of maximally suppressing viral replication. The clinical benefits of HAART are significant and durable. Drugs have important interactions with other medication. Interactions need to be reviewed carefully. Medication or Dosage Description Rationale Drug Class Antiretroviral Varies by drug Nucleoside analog Decreases HIV therapy replication by classifications: incorporation into Nucleoside analog the strand of DNA, reverse leading to chain transcriptase termination inhibitors Antiretroviral Varies by drug Nucleoside analog Blocks the action of therapy the viral protease classification: required for protein protease inhibitors processing near the end of the viral cycle Antiretroviral Varies by drug Non-nucleoside Inhibits HIV by therapy: reverse binding nonnucleoside transcriptase noncompetitively to reverse inhibitors reverse transcriptase transcriptase inhibitors Antiretroviral Varies by drug New class of Targets different therapy: HIV entry antiretroviral stages of the inhibitors agents HIVentry process NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- Independent Nursing interventions are complex because of the many physical, psychological, and social effects that occur from HIV infection and AIDS. During the more acute stages of the illness, focus on maximizing the patient’s health and promoting comfort. Educate the patient and significant others regarding self-care by keeping any lesions and the skin clean and dry. Diarrhea can limit activities and also cause pain, both abdominal and perianal, if any lesions are present. Keep the perianal area clean, and assist the patient to clean himself or herself immediately. Instruct the patient about the food substances that are GI irritants. Explain that diarrhea can cause dehydration, electrolyte disturbances, and malabsorption; provide the patient with ways to maintain fluid and electrolyte balance. All patients need to be instructed to perform frequent and thorough oral care. Teach patients to avoid toothbrushes. Tell them to clean the teeth, gums, and membranes with a soft gauze pad; to use mouthwashes without alcohol; to lubricate the lips; and to avoid foods that are spicy, acidic, thermally hot, and hard to chew. Also explain the need to seek treatment for Candida and herpes and to use lidocaine (Xylocaine) for discomfort. Explain the mechanisms for HIV transmission and teach the patient and significant others the precautions regarding transmission by both casual and sexual routes. Explain that if the patient has spills of blood or secretion, they should be cleaned up with a 1:10 solution of bleach and water to limit the risk of infection to others. Use universal precautions whenever you are exposed to blood, body fluids, or secretions, and teach the patient’s significant others to do the same. Note that the best outcomes result from early intervention. Many times, the patient’s family members are unaware of her or his bisexual or homosexual orientation, or women may be unaware that their partner had high-risk behavior that exposed them to HIV infection. The diagnosis of AIDS may increase the distance between friends and family members. Social isolation often occurs because others avoid the patient out of the fear of being infected. Allow the patient to talk about the diagnosis and isolation. Use touch and encourage others to touch, hug, hold hands, and give back rubs to the patient to help fulfill the patient’s need for touch. Encourage the patient’s participation in support groups and use of volunteer “friends.” The patient may experience anger, denial, anxiety, hopelessness, and depression. Ensure that the needed support services are available for home healthcare; make sure the patient has support for meals, financial assistance, and hygienic care. DOCUMENTATION GUIDELINES Physical changes: Weight, mental status, vital signs, skin integrity, bowel habits Tolerance to activity, fatigue, ability to sleep, ability to manage self-care Emotional response, coping, signs of ineffective coping, support from family and friends Presence of opportunistic infections, complications of infections, medications, resistance, NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  recurrence Requests for management of the critical phases of disease, and pertinent information about the patient’s wishes regarding the final stages of life DISCHARGE AND HOME HEALTHCARE GUIDELINES PREVENTION. Teach the patient or caregiver universal precautions at home; adequate nutritional strategies; the names and telephone numbers for support organizations; self-assessments daily for temperature elevations; signs of thrush (Candida), herpes, and other opportunistic infections; symptoms of complications such as cough, lesions, and fever; strategies to limit situations with high infection potential (crowds, people with colds or flu). TRANSMISSION. Teach the patient strategies to practice safe sex. Inform the patient that the disease can be transmitted during high-risk sexual practices that expose partners to body fluids. These practices include vaginal and anal intercourse without a condom, or oral sex without protection. Encourage the patient to use safe sex practices such as hugging, petting, mutual masturbation, and protected anal and vaginal sex. Encourage the patient to notify any sexual partners and healthcare providers that she or he has an HIV infection. Explain that the patient should not donate blood, blood products, or organs, tissues, or sperm. If the patient continues to abuse intravenous drugs, make sure the patient knows never to share needles. Explain to women of childbearing age that any pregnancy may result in an infant with an HIV infection. Explain that HIV may also infect an infant during delivery or during breastfeeding. Encourage the woman to notify her physician as soon as pregnancy occurs to allow preventive treatment to limit the risk to the fetus. SUPPORT SYSTEMS. Inform the patient about the possible physiological, emotional, and mental effects of the disease, along with the treatments and resources that are available to them. Encourage the patient to explore hospice care early in the treatment cycle to establish a possible long-term relationship as the disease progresses. CRITICAL THINKING LEARNING ACTIVITY Case Study: AEP is a 42 year old male who resides with his partner. AEP was diagnosed several months ago when he presented to the NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  doctor’s office with dysphagia, chronic cough, diarrhea, weight loss, night sweats, lymphadenopathy and fever, all lasting well over a month. a. What pathogen or pathogens might account for his cough? b. What medication(s) might we use to treat him? c. Why does he have diarrhea? What causative pathogens could be causing this? d. Why do patients with AIDS lose weight? What medications might we give to increase appetite? e. Why might AEP have a sore throat? f. AEP subsequently developed visual blurring. What pathogen might be causative? How would we treat this? g. What lab tests may have been used to arrive at his diagnosis of AIDS? What category would he be, given his conditions? h. What treatments might we institute to slow the progression of his illness? i. AEP was started on didanosine, nevira and norvir. Thereafter, JO’s symptoms markedly improve. His CD4 count improved from 200 to 500. However, after being on this combination therapy for several months, JO developed lipoatrophy of his face and legs and his triglycerides were 6000. Which drug warrants discontinuation? B) Sexually Transmitted Disease a. Chlamydial Infections Infection with Chlamydia trachomatis is the most common sexually transmitted infection (STI) in the United States today, with approximately 5 million cases reported annually. While chlamydial infections are reportable in all 50 states, underreporting of this STI is substantial owing to the number of individuals who may have the infection and not know it. Because 70% of women and 50% of men with chlamydial infections are asymptomatic, they transmit the disease but are unaware that they harbor the bacteria. Untreated infections in women can NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- result in cervicitis, endometritis, acute salpingitis, bartholinitis, irregular menses, ectopic pregnancy, pelvic inflammatory disease, and infertility. Untreated infections in men can result in nongonococcal urethritis (NGU), epididymitis, or prostatitis. Infections in either gender can result in proctitis, lymphogranuloma venereum (LGV), and, potentially, infertility and sterility. During pregnancy, C. trachomatis may be transmitted from mother to fetus, which may cause premature rupture of the membranes, premature labor, and increased fetal morbidity and mortality. Pregnant women who deliver vaginally or by cesarean section can transmit the bacteria to their infants. These newborns can develop otitis media, conjunctivitis, blindness, meningitis, gastroenteritis, respiratory infections, and pneumonia. Because mothers are often asymptomatic, medical personnel are unaware that the maternal-infant transmission has occurred until infants become very ill. CAUSES C. trachomatis is an obligate, gram-negative, intracellular bacterium with several different immunotypes. It resembles a virus in that it requires a tissue culture for isolation, but like a bacteria, it has RNA and DNA and is susceptible to antibiotics. It is transmitted through sexual intercourse and from mother to fetus during birth. The chlamydial infection exists in two forms: The elementary bodies are the infectious particles that enter uninfected cells; and the reticulate bodies are an active form of the organism that reproduce and form more elementary bodies that are released from the bursting infected cell and can then infect other cells. Replication begins only 12 hours after invasion. The pathogen invades and reproduces inside of the cells that line the cervix, endometrium, fallopian tubes, and urethra. Symptoms can occur after a 1- to 3-week incubation period; however, overt symptoms often occur late in the disease. GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS Although the occurrence of chlamydial infection is related more to sexual practices than to age, many women with chlamydial infection are young, under 24 years of age, and single. Indigent women with no prenatal care are a high-risk group. The rate of infection is also highest in African American women, and it is highest in the southern states. With more teens engaging in sexual activity, more adolescents of both genders are contracting infections. Depending on the population, 5% to 35% of pregnant women are infected with C. trachomatis. ASSESSMENT HISTORY. Although sexual activity is potentially a sensitive topic, it is critical to obtain a detailed sexual and gynecologic history. Inquire about the number of partners, use of barrier protection and birth control measures, participation in oral or anal intercourse, and previous STIs. Most patients who present with C. trachomatis have a history of multiple sex partners and engaging in sexual intercourse without the use of barrier protection. Often, patients are also positive for gonorrhea. Inquire if the patient has any thin or purulent discharge, burning or frequent urination, mucus-covered stools, lower abdominal NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- pain, dyspareunia (painful sexual intercourse), headache, nausea, vomiting, chills, or bleeding after intercourse. Often, patients are asymptomatic, and some may complain only of an increase in vaginal discharge. Male patients may report dysuria, urinary frequency, and pruritus. Ask the patient if she or he is experiencing any diarrhea, tenesmus, or pruritus, any of which indicates that the infection involves the rectum. PHYSICAL EXAMINATION. For females, inspect the vagina, cervix, and labia and note any mucopurulent discharge. Bartholin glands may be involved. Gently touch the cervix; note any bleeding (friable cervix). Inspect males for purulent discharge at the urinary meatus. Scrotal swelling occurs if the organism has caused epididymitis. Inspect the anus for discharge and excoriation. If LGV is present, ulcerative lesions on the cervix, vagina, labia, anal/rectal area, or penis may occur. Enlarged lymph nodes also can be palpated in the groin. If these nodes rupture, they secrete a thick yellow granular substance. PSYCHOSOCIAL. Assess the patient’s knowledge of STIs and the implications. Assess the patient’s ability to cope with having an STI. The diagnosis of an STI can be very upsetting to a male or female who believes he or she was involved in a monogamous relationship. Patients may feel embarrassed and guilty about their condition. Inquire about the patient’s ability to obtain condoms. Identify all partners with whom the patient has been sexually active so that they can be examined and treated. Assess the patient’s support system; this is especially important if the patient is pregnant. PLANNING AND IMPLEMENTATION Collaborative Chlamydial infections can easily be cured with oral antibiotics, and patients are rarely hospitalized. Patients need to know to continue to take medication as ordered, even if the symptoms subside. Follow-up with both partners is recommended to assure that neither partner is still infected. Patients should abstain from sexual intercourse until they are infection free. Independent Because patients are often asymptomatic, nurses need to identify those patients at risk for chlamydial infections and recommend screening. Prevention is an important nursing intervention. Teach patients that monogamous relationships with uninfected partners, use of mechanical barriers, and simultaneously treating the partner to prevent reinfection are ways to prevent transmission of C. trachomatis. Emphasize that it is possible for them to carry and transmit the bacteria, even if they are asymptomatic. Since a chlamydial infection is easily cured by antibiotics, teach the patient about taking the medications properly. Instruct patients to take all medication until the course of treatment is finished, even if the symptoms subside. Explain that the patient should abstain from intercourse until all medication is gone to prevent reinfection. For discomfort, NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- teach the patient about warm sitz baths and taking prescribed analgesics as ordered. DOCUMENTATION GUIDELINES Screening done and results if available; note if a female patient is pregnant Physical signs and symptoms: Discharge (amount, color, odor, location), pain, bleeding, swelling, dysuria Patient’s reaction to the diagnosis of an STI Patient’s understanding of diagnosis, treatment, and prevention DISCHARGE AND HOME HEALTHCARE GUIDELINES MEDICATIONS. Be sure the patient understands the correct dosage, route, and time of the medication, as well as the importance of taking all prescribed medication, even if the symptoms resolve. Emphasize any dietary restrictions. PREVENTION. Teach the patient about the importance of barrier contraception, especially latex condoms. Often, patients on oral contraceptives do not realize that, although they probably will not get pregnant, they are not protecting themselves from STIs. Emphasize the importance of follow-up visits to assure that the infection has resolved. Encourage the patient to enforce follow-up of all sexual partners and to refrain from intercourse during antibiotic therapy to prevent reinfection. While experts recommend that all women less than 25 years of age be screened annually for chlamydia, this recommendation for routine screening does not include men. COMPLICATIONS. Teach the patient about potential long-term complications such as infertility and sterility if reinfection occurs. b. Gonorrhea Gonorrhea is one of the most common sexually transmitted infections (STIs) in the United States. The risk of developing the infection from intercourse with an infected partner is between 50% and 90% for females and is 20% for males. The risk for males increases three- to fourfold after four exposures. Two types of infection develop: local and systemic (disseminated). Local infection involves the mucosal surfaces of the genitourinary tract, rectum, pharynx, or eyes. Systemic infections occur because of bacteremia and can lead to multisystem involvement with connective tissues, the heart, and the brain. If left untreated, gonorrhea will involve the fallopian tubes, ovaries, and peritoneum, resulting in gonococcal pelvic inflammatory disease (PID) in women. Systemic complications of untreated, or undertreated, infections are disseminated gonococcal infections that lead to acute arthritis, tenosynovitis, NCM 112_LEC_authoredby:melchiepulidoMAN -Module I-  dermatitis, polyarthritis, endocarditis, and meningitis. With adequate treatment, most people recover fully, but reinfection is common. If gonorrhea is contracted during pregnancy, preterm premature rupture of membranes, preterm birth, and increased risk for neonatal morbidity and mortality exist. CAUSES: Gonorrhea is an STI caused by the bacterium Neisseria gonorrhoeae, an aerobic, pyrogenic, gram negative diplococcus that produces inflammatory reactions characterized by purulent exudates. The organism grows best in warm, mucus-secreting epithelia and can enter the body through the genitourinary tract, eyes, oropharynx, anorectum, or skin. An infant born to an infected mother can contract gonorrhea when it passes through the birth canal. Self-inoculation to the eyes can also occur if a person with gonorrhea touches his or her eyes with a contaminated hand. Risk factors include multiple sex partners, an unknown sex partner, and unprotected sexual contact. GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS Gonorrhea is particularly prevalent in the young adult population between the ages of 15 and 29; the highest incidence of infection is in the 20- to 24-year- old age group. ASSESSMENT HISTORY. Take a complete sexual history. To direct specimen collection, elicit information regarding sexual orientation and sexual practices (vaginal, oral, and anal). To determine treatment plans, inquire about medication allergies. Explore the patient’s birth control practices and determine if the patient and partner regularly use condoms. Explore the number of sex partners, the incidence of unprotected sexual contacts, and the frequency of sex with unknown partners. Men usually develop symptoms of urethritis 2 to 5 days after exposure, but symptoms may not appear until 3 weeks later. Usually, the first symptom is a purulent yellow or greenish-yellow penile discharge. In addition, dysuria, urinary frequency, and malaise may also be present. If the infection remains untreated after 10 to 14 days, it spreads from the anterior urethra to the posterior urethra, resulting in more intense dysuria, headaches, and lymphadenopathy. Untreated, the infection can result in prostatitis, epididymitis, and cystitis. With an anorectal infection, there is often a history of mucopurulent rectal discharge, rectal bleeding, rectal pain, and changes in bowel habits. Inspection will reveal erythema and discharge from the rectal and anal mucosa. In women, the incubation takes at least 2 weeks, although women are often asymptomatic. Symptoms include yellowish or greenish vaginal discharge, dysuria, urinary frequency, vaginal spotting between periods, heavy menses, NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- backache, and abdominal and pelvic pain. In addition, there may be pruritus and burning of the vulva. If the infection is left untreated, it may ascend to the pelvic cavity, resulting in pelvic pain and fever. Frequently, women have a gonococcal infection involving the rectum and anus, presumably from the spread of the exudate. Approximately one-third to one-half of all women who develop gonorrhea have a chlamydial infection as well. PHYSICAL EXAMINATION. The patient may appear uncomfortable with symptoms of a local infection and may be mildly ill with a low-grade fever. When you inspect the female genitalia, you may note a greenish-yellow discharge from the Skene’s or Bartholin’s glands, along with a mucopurulent discharge at the cervical os. The vagina is engorged, red, and swollen. The cervix is usually friable and erythematic. Abdominal palpitation will reveal both lower quadrant and rebound tenderness. Pelvic examinations will be painful, especially with cervical movement. Urethritis Gonococcus fistula in penis Urethritis,accompanied with balanitis Double gonococcus fistula in glans The male’s urethral meatus usually has purulent discharge. An anal infection in either gender leads to purulent discharge and bleeding from the rectum. In newborns, gonorrheal conjunctivitis appears 1 to 12 days after birth. If conjunctivitis is left untreated, blindness results from corneal ulcerations. Symptoms include bilateral edema of the lid, followed by a profuse purulent discharge from the eye. Examination of the patient with a systemic infection may reveal papillary skin lesions that appear as pustules or hemorrhages on the hands and feet. Joint motion causes the patient severe pain, and you may hear a cracking noise when joints are moved through their range of motion. In gonococcal arthritis, the joints NCM 112_LEC_authoredby:melchiepulidoMAN -Module I- are asymmetrically involved and only certain joints (knees, ankles, elbows) are usually affected. PSYCHOSOCIAL. When taking a sexual history and counseling on sexual matters, be sensitive to the patient’s need for privacy and yet be aware of the public health responsibility to report STIs. Urge the patient to notify all sexual partners of the infection promptly so that they canreceive treatment. Because gonorrhea is an STI, sexual abuse should be considered when it is diagnosed in a child. Follow up immediately with appropriate refe