NUPC-113-MODULE-II PDF

MODULE II CARE OF CLIENTS WITH PROBLEMS IN INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE Lesson 1 Overview of the Immune System Lesson 2 The Nursing Process Lesson 3 Responses to Alterations Prepared by: JIMA J. MAMUNGAY First Seme...

MODULE II CARE OF CLIENTS WITH PROBLEMS IN INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE Lesson 1 Overview of the Immune System Lesson 2 The Nursing Process Lesson 3 Responses to Alterations Prepared by: JIMA J. MAMUNGAY First Semester, SY 2021-2022  2 TABLE OF CONTENTS 3 Introduction 125Learning Activity 3 Learning Outcomes 126Module Summary 3 Module Organizer 127References 4 Directions 129Appendix 6 Lesson 1 55 Lesson 4 5 Pretest 54 Pretest 6 Overview 55 Ulcerative Colitis 59 Crohn’s Disease 19 Lesson 2 61 Appendicitis 18 Pretest 63 Peritonitis 27 Nursing Assessment 65 Pancreatitis 28 Nursing Diagnosis 70 Cholecystitis 28 Planning and Implementation 73 Urinary System 31 Evaluation 79 Reproductive System 84 Integumentary 33 Lesson 3 89 Lesson 5 32 Pretest 88 Pretest 33 Pneumonia 89 Multiple Sclerosis 35 Pulmonary Tuberculosis 92 Diabetes Mellitus 39 Ebola 105 Ulcerative Colitis 41 Hepatitis 105 Acute 44 Guillain-Barre Syndrome Glomerulonephritis 48 Chlamydia Trachomatis 106 Systemic Lupus 49 Genital Herpes Erythematous 51 Gonorrhea 107 Rheumatoid Arthritis 111 Human Immunodeficiency Virus Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  3 MODULE II CARE OF CLIENTS WITH PROBLEMS IN INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE INTRODUCTION This module introduces Care of Clients with Problems in Infectious, Inflammatory and Immunologic Response as part of your course Care of Client with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations, Acute and Chronic. Care of Clients with Problems in Infectious, Inflammatory and Immunologic Response deals with the normal and abnormal responses of the body against illness or diseases. It tackles how our immune system protects the body with their physiologic defense mechanisms. This module will help you deliver and prioritize appropriate, safe and correct interventions or patient’s care that have problem in infectious, inflammatory and immunologic response that will enhance your capabilities to become a good and responsible nurse in the future. LEARNING OUTCOMES After studying the module, you should be able to: 1. apply appropriate nursing concepts and actions holistically and comprehensively. 2. utilize the nursing process in the care and health education of patients with problems in infectious, inflammatory and immunologic response. 3. ensure a well-organized and accurate documentation system of patient with infection/altered immune response. 4. demonstrate good and proper inter-professional collaboration in rendering care to patients with problems in infectious, inflammatory and immunologic response. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  4 5. show safe and appropriate care to patients based from their culture and practices. 6. integrate relevant legal, moral and ethical standards of care in performing the roles and responsibilities of a nurse 7. apply evidence-based practices in caring of a patient with problems in infectious, inflammatory and immunologic response. 8. plan an effective care to promote, maintain, or restore functional health patterns to client with infections. MODULE ORGANIZER Hi! My name is Jima Jose Mamungay. I will be your instructor for this course. In case you encounter difficulty, discuss this with me during the scheduled face-to-face meeting at the CCHAMS Faculty Office or virtual meeting. If not, contact me to this following contact details: [email protected] Jima Querrer Jose Mamungay 09178417848 MODULE GUIDE There are three lessons in the module. Before you begin each lesson, you will take the pretest first to determine if you are sufficiently prepared to begin. Read each lesson carefully. Lesson 1 to 3 starts with the brief overview of the topic and followed by steps in the nursing process then the response of an individual with these alterations. After reading each lesson, you are required to answer the exercises/activities to find out how much you have benefited from it. Work on these exercises carefully because they are graded and submit your output to my email given to you. Rubrics will be used to evaluate your outputs that are seen in the appendix section of this module. As you go along, there are important aspects of care that are highlighted. These aspects include the following: 1. NURSING SAFETY PRIORITY Boxes which highlights important information you can use to avoid patient harm. These are further categorized as Action Alert and Critical Rescue. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  5 2. QSEN or Quality and Safety Education for Nurses reflect your role as a nurse in the health care system that improves quality and safety nursing interventions/actions. Moreover, these boxes reflect both competencies and quality measures that will help you become effective, safe, and efficient nurse who renders patient-centered care across settings. Good luck and happy reading!!! PRETEST Before you start our first lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Immune System. Write your answer in a piece of paper. Good luck. Be honest to yourself. TRUE or FALSE. Read each statement below carefully. Place a T on the line if you think a statement is TRUE. Place an F on the line if you think the statement is FALSE. Good luck __________1. Immunity is protection from illness or disease that is maintained by the body's physiologic defense mechanisms. __________2. Natural passive immunity occurs when an antigen enters the body and the body creates antibodies to fight off the antigen. __________3. Natural active immunity occurs when antibodies are passed from a mother to the fetus through the placenta or using colostrum or the breast milk. __________4. Artificial active immunity occurs via a vaccination or immunization. __________5. Artificial passive immunity occurs via a specific transfusion such as immunoglobulins. __________6. Transplant rejection is an abnormal response of the immune system that can damage or destroy the transplanted organ. __________7. Bone marrow is the source of all blood cells, including most immune system cells. It produces immature, undifferentiated cells called stem cells. __________8. Phagocytosis is the engulfing and destruction of invaders. __________9. Immunity is an adaptive internal protection that results in long- term resistance to the effects of invading microorganisms. __________10. Immunocompetence requires that inflammation, antibody mediated, and cell-mediated responses all have optimal functioning. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  6 “Motivation is what gets you started. Habit is what keeps you going” -Jim Ryun “Push harder than yesterday if you want a different tomorrow” -Unknown Lesson 1 Overview of the Immune System Overview As we all know, immunity is protection from illness or disease that is maintained by the body's physiologic defense mechanisms. Mechanism of Acquisition of Immunity Active Passive Natural Acquired Natural active immunity occurs when an antigen enters the body and the body creates antibodies to Natural passive immunity fight off the occurs when antibodies are antigen. passed from a mother to the fetus through the placenta or using colostrum or the breast milk. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  7 Artificial Artificial Acquired active immunity occurs via a vaccination or immunization. Artificial passive immunity occurs via a specific transfusion such as immunoglobulins. Multiple organs and cells in the body are involved in the immune response. Antibody-mediated immunity (humoral immunity) includes the antigens and antibodies interacting in an attempt to slow down or destroy the foreign body. B-cells play a major role in this activity, together with the macrophages, T-lymphocytes (T-cells), and spleen. Cell-mediated immunity involves the functions of numerous cells to fight off the antigen, including white blood cells (WBCs), T-cells, natural killer (NK) cells, and multiple cytokines. The thymus and lymph nodes also play a role in this immune process. Inflammation and immunity are provided through the actions and products of white blood cells (WBCs), also called leukocytes. There are several types of WBCs, and these cell types are the basis of the differential of the WBC count. The differential can be used to determine the patient's risk for infection, the presence or absence of infection, the presence or absence of an allergic reaction, and whether an infection is bacterial or viral. WBCs provide protection through defensive actions such as recognition of self versus non-self. Self-tolerance is the special ability of WBCs to recognize healthy self cells using proteins in cell membranes. WBCs are the only body cells able to recognize non-self cells and to attack them. One example of membrane proteins that provide self-identification is human leukocyte antigens (HLAS) found on the surface of most body cells. HLAs are inherited and determine tissue type. Other defensive actions by which WBCs provide protection include: 1. Destruction of foreign invaders, cellular debris, and unhealthy or abnormal self cells. 2. Production of antibodies directed against invaders 3. Complement activation 4. Production of cytokines that stimulate WBC production in bone marrow and increase specific leukocyte activity Immunocompetence requires that inflammation, antibody mediated, and cell- mediated responses all have optimal functioning. Inflammation is a general, Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  8 nonspecific protective response. I. Inflammation a. Inflammation and infection is not the same thing. Infection almost always is accompanied by inflammation, but inflammation often occurs without infection. b. The tissue responses to inflammation are helpful if they are confined to the area of invasion or infection and do not extend beyond the acute phase. Chronic inflammation can damage tissues and reduce function. c. Inflammation cannot be transferred from one person to another. II. Immunity is an adaptive internal protection that results in long-term resistance to the effects of invading microorganisms. There are two types: a. Antibody-mediated immunity (AMI), also known as humoral immunity 1. Antigen-antibody interactions neutralize, eliminate, or destroy foreign proteins. 2. Antibodies are produced by sensitized B-lymphocytes (B- cells). 3. AMI can be transferred from one person or animal to another for a short-term effect. b. Cell-mediated immunity (CMI) that controls and coordinates the entire inflammatory and immune response Inflammation and Immunity III. Immune function peaks between 20 and 40 years of age; the older adult is at an increased risk for infection and cancer development. IV. Patients who take immunosuppressive drugs for any reason have an increased risk for infection and cancer development. V. Transplant rejection is a normal response of the immune system that can damage or destroy the transplanted organ. Patients who receive transplanted organs (unless they are from an identical sibling) need to take immunosuppressive drugs daily to prevent transplant rejection. ORGANIZATION OF THE IMMUNE SYSTEM The immune system is not located in any one organ or body area, but most immune system cells come from the bone marrow. Some cells mature in the bone marrow; others leave the bone marrow and mature in different body sites. When mature, many immune system cells are released into the blood, where they circulate to most body areas and have specific effects. Bone marrow is the source of all blood cells, including most immune system cells. It produces immature, undifferentiated cells called stem cells. Stem cells are pluripotent/ flexible (each cell has more than one potential outcome). It could become any one of many mature blood cells. Figure 1 shows how stem cell differentiates and matures. Each WBC has a specific function. The cells of the immune system and their Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  9 functions are as follows: 1. Neutrophils nonspecifically ingest and phagocytize microorganisms and foreign protein. 2. Macrophages nonspecifically recognize foreign proteins and microorganisms, ingesting and phagocytizing these invaders. 3. Monocytes destroy bacteria and cellular debris; they also mature into macrophages. 4. Eosinophils have weak phagocytic action and release vasoactive amines during allergic reactions. 5. Basophils release histamine and heparin in areas of tissue damage. 6. Lymphocytes have two categories of specialized cells, each with subtypes: a. B-lymphocytes are essential to AMI. They sense foreign cells and proteins and exist as either plasma cells or memory cells, secreting immunoglobulins in response to the presence of a specific antigen. b. T-lymphocytes are essential to CMI and are further characterized as helper or inducer T-cells (which enhance immune activity through secretion of various factors, cytokines, and lymphokines), suppressor T-cells (which regulate immune activity by preventing hypersensitivity), cytotoxic or cytolytic T-cells (which selectively attack and destroy non-self cells, including virally infected cells, grafts, and transplanted organs), or natural killer (NK) cells (which nonselectively attack non-self cells, especially body cells that have undergone mutation and become malignant; they also attack grafts and transplanted organs). Table 1 shows the immune functions of Specific Leukocytes Figure 1. Stem Cell Differentiation and Maturation Table 1. Immune Functions of Specific Leukocytes VARIABLE LEUKOCYTE FUNCTION Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  10 Neutrophil Nonspecific ingestion and phagocytosis of microorganism and foreign protein Macrophage Nonspecific recognition of foreign proteins and microorganism; ingestion and phagocytosis Assists with antibody-mediated immunity and cell- mediated immunity Inflammation Destruction of bacteria and cellular debris; matures Monocytes into macrophage Eosinophil Releases vasoactive amines during allergic reactions to limit these reactions Basophil Releases histamine and heparin in areas of tissues damage B-Lymphocyte Becomes sensitized to foreign cells and proteins with the assistance of macrophages and helper/inducer T- cells Antibody- Plasma cell Secretes immunoglobulins in response to the presence mediated of a specific antigen immunity Memory cell Remains sensitized to a specific antigen and can secrete increased amounts of immunoglobulins specific to the antigen on re-exposure Helper/ Inducer Enhances immune activity of all parts of general and T-cell specific immunity through secretion of various factors, cytokines, and lymphokines. Cytotoxic/ Selectively attacks and destroys non-self cells, Cell-mediated cytolytic T-cell including virally infected cells, grafts, and immunity transplanted organs Natural killer Nonselectively attacks non-self cells, especially body cell cells that have undergone mutation and become malignant; also attacks grafts and transplanted organs Phagocytosis is the engulfing and destruction of invaders. This action also rids the body of debris after tissue injury. Neutrophils and macrophages are most efficient at phagocytosis. Phagocytosis involves seven steps: 1. Exposure and invasion: For phagocytosis to start, leukocytes must first be exposed to organisms, foreign proteins, or debris from damaged tissues. 2. Attraction: To ensure the WBCs come into direct contact with the target (antigen, invader, or foreign protein), damaged tissues and blood vessels secrete chemotaxins (chemical attractants) that can combine with the surface of invading foreign proteins to improve attraction. 3. Adherence: This process allows the phagocytic cell to bind to the surface of the target. 4. Recognition: This process occurs when the phagocytic cell sticks to the surface of the target cell and recognizes it as non self. This action ensures that phagocytosis occurs only against non-self or unhealthy self cells. 5. Cellular ingestion: Phagocytosis (engulfment) into the phagocyte is Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  11 needed because the destruction of the target cell occurs inside the phagocytic cell. 6. Phagosome formation: This occurs when the phagocyte's granules are inside the vacuole and fuse to the invader. 7. Degradation: The phagosome enzymes digest the engulfed target, which is the final step. INFLAMMATION Inflammation, also called natural or innate-native immunity, provides immediate protection against the effects of tissue injury and invading foreign proteins. Inflammation is characterized by blood vessels and tissue reactions to rid the body of harmful microorganisms and other invaders. Inflammation differs from immunity in two important ways: 1. Inflammatory protection is immediate but short term against injury or invading organisms. It does not provide true immunity on repeated exposure to the same organism and cannot be transferred to another person. 2. Inflammation is a nonspecific body defense to invasion or injury and can be started by almost any event, regardless of where it occurs or what causes it. The classic manifestation of inflammation are: 1. Warmth 2. Redness 3. Swelling 4. Pain 5. Decreased function Symptoms of inflammation can be local or widespread, depending on the intensity severity, and duration of exposure to the initiating injury or invasion. Inflammation occurs in response to tissue injury and to invasion by organisms. Infection is usually accompanied by inflammation; however, inflammation can occur without infection 1. Examples of inflammation without infection include sprain injuries to joints, myocardial infarction, sterile surgical incisions, blister formation, and thrombophlebitis. 2. Examples of inflammation caused by noninfectious invasion by foreign proteins include allergic rhinitis, contact dermatitis, and other allergic reactions. 3. Examples of inflammation caused by infection include pneumonia, appendicitis, and viral hepatitis. Four types of WBCs ( leukocytes) are involved in inflammation: 1. Neutrophils 2. Macrophages 3. Eosinophils 4. Basophils Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  12 SEQUENCE OF INFLAMMATORY RESPONSE Inflammatory responses occur in a predictable sequence of three stages. The sequence is the same regardless of the triggering event, and the timing may overlap. 1. Stage I is the vascular part of the inflammatory response. Injured tissues and the leukocytes in this area secrete histamine, serotonin, and kinins that constrict the small veins and dilate the arterioles in the area of injury. Increased blood flow and capillary permeability deliver nutrients to injured tissues but also cause redness, swelling and pain. The duration of Stage 1 depends on the severity of the initiating event but usually subsides within 24 to 72 hours. 2. Stage II is the cellular exudate part of the response, Neutrophilia (increased number of circulating neutrophils) occurs. Exudate in the form of pus occurs, containing WBCs, the pathogen, necrotic tissue, and fluids. a. The neutrophils can increase in count up to five times within 12 hours after the onset of inflammation as a result of cytokine stimulation. b. Neutrophils destroy organisms and remove dead tissue through phagocytosis. c. The arachidonic acid (AA) cascade contributes to the inflammatory response by converting fatty acids in plasma membranes into AA. Enzymes (including cyclooxygenase) then convert AA into many chemicals that are further processed into the substances that continue the inflammatory response in the tissues. Some of these substances include histamine, leukotrienes, prostaglandins, serotonin, and kinins 3. Stage III features tissue repair and replacement. Although this stage is completed last, it begins at the time of injury abs id critical to healing. a. Some of the WBCs involved in inflammation start the replacement of lost tissues or repair of damaged tissues releasing growth factors, inducing the remaining healthy cells to divide. b. In tissues that are unable to divide, molecules released by WBCs trigger new blood vessel growth (angionesis) and scar tissue formation. Because scar tissue does not behave like normal tissue, loss of function occurs wherever damaged tissues are replaced with scar tissue. CONSEQUENCES OF INFLAMMATION Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  13 When inflammation occurs in response to invasion by infectious microorganisms, its actions can eliminate or destroy the invaders and prevent the person from becoming ill. Inflammation is needed to trigger both AMI and CMI. When inflammation response are prolonged or occur at inappropriate times or in inappropriate places, they can cause tissue damage with extension fibrosis, scarring, and loss of healthy tissue function. IMMUNITY Lymphocytes develop actions and products that provide the protection of true immunity. ANTIBODY – MEDIATED IMMUNITY AMI, also known as humoral immunity, involves antigen – antibody interactions to neutralize, eliminate, or destroy foreign proteins. Antibodies are produced by B-lymphocytes (B-cells). B-cells become sensitized to a specific foreign protein (antigen) and produce antibodies directed specifically against that protein. The expressed antibody (rather than the B-cells) causes one of several actions to neutralize, eliminate, or destroy that antigen. B-cells start as lymphocytes in the bone marrow, the primary lymphoid tissue, and migrate into many secondary lymphoid tissues, where maturation is completed. The secondary lymphoid tissues for B-cells maturation are the spleen, parts of lymph nodes, tonsils, and the mucosa of the intestinal tract. Seven steps are needed to produce a specific, long-lasting antibody directed against a specific antigen whenever the person is exposed to that antigen: 1. Exposure on invasion is needed because antibody actions occur inside the body or on a few body surfaces. Without exposure, an antibody cannot be made. 2. Antigen recognition is the recognition of the invader by an unsensitized B-cells. This process involves macrophages and helper-inducer T-cells. 3. Lymphocytes sensitization occurs when the B-cell recognizes the antigen as non-self and becomes sensitized to this antigen. A single naïve B-cell can become sensitized only once. 4. Antibody production and release occurs at rate as high as 300 molecules of antibody per second by each sensitized B- lymphocyte. These antibody molecules are released and can bind to their specific antigen. Circulating antibodies can be transferred from one person to another to provide the receiving person with immediate immunity of short duration. 5. Antibody-antigen binding occurs when the tips of the Y- shaped antibody recognize the specific antigen and bind to it. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  14 He binding stimulates reactions to neutralize, eliminate, or destroy the antigen. 6. Antibody-binding actions include agglutination, lysis, complement fixation, precipitation, and inactivation or neutralization, all of which can neutralize, eliminate, or destroy the antigen. 7. Sustained immunity (memory) is critical in providing long lasting immunity to a specific antigen. It results from memory B-cells made during the lymphocyte sensitization stage. These memory cells remain sensitized to the specific to which they were originally exposed. On re-exposure to the same antigen, the memory cells rapidly respond, and each new cells can rapidly make large amounts of the antibody specific for sensitizing antigen. This ability of the memory cells to respond on re-exposure to the same antigen that originally sensitized the B-cells allows a rapid and large immune (anamnestic) response to the antigen. Such large quantities of antibody are made that the invading organisms usually are removed completely, and the person does not become ill. Because of this process, most people do not become ill with chickenpox or other infectious disease more than once, even though they are exposed many times to the causative organism. Without the action of memory, people would remain susceptible to specific diseases on subsequent exposure to the organisms, and no sustained immunity would be generated. All antibodies are immunoglobulins (Ig), also called gamma globulins, because they are globular proteins that confer immunity. There are five antibody types: 1. IgA is the secretory antibody found on body surfaces and secretions to prevent antigen entry. 2. IgM is the antibody type a sensitized B-cell makes on first exposure to an antigen. It is a large and complex structure with 10 binding sites. IgM is a powerful antibody, even though it is produced in small amounts. This antibody ensures that an initial infectious illness, such as chickenpox, last only 5 to 10 days. 3. IgG is the most common antibody found in the blood. On re- exposure to the same antigen, the already sensitized B-cell makes large amounts of the IgG type of antibody against that antigen. The enormous numbers produced make IgG antibodies efficient at clearing the antigen and protecting the person from again becoming ill with the disease. 4. IgE is the antibody type that is responsible for many allergic reactions. 5. IgD activates B-cells and modifies the activity of IgM. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  15 ACQUIRING ANTIBODY-MEDIATED IMMUNITY Adaptive immunity is the immunity that a person’s body learns to make (or can receive) as an adaptive response to invasion by organisms or foreign proteins. AMI is an acquired immunity, is active or passive, and is acquired naturally or artificially. 1. Active immunity occurs when antigens enter the body and the body responds by actively making specific antibodies against the antigen. a. Natural active immunity occurs when an antigen enters the body without human assistance and the body responds by actively making antibodies against that antigen (e.g., chickenpox virus). This type of immunity is the most effective and the longest lasting. b. Artificial active immunity is the protection developed by vaccination or immunization. Small amounts of specific antigens are placed as a vaccination into a person and the immune system responds by actively making antibodies against the antigen. 2. Passive immunity occurs when antibodies against an antigen are in a person’s body but were transferred to the person’s body after being made in the body of another person or animal. It provides only immediate short-term protection against a specific antigen. a. Natural passive immunity occurs when antibodies are passed from the mother to the fetus through the placenta or to the infant though colostrum and breast milk. b. Artificial passive immunity involves injecting a person with antibodies that were produced in another person or animal. AMI works with inflammation to protect against infection. However, AMI can provide the most effective, long-lasting immunity only when its actions are combined with those of CMI. CELL-MEDIATED IMMUNITY CMI, or cellular immunity, involves many WBC actions and interactions. This type of immunity is provided by lymphocytes stem cells that mature in the secondary lymphoid tissues or the thymus and pericortical areas of lymph nodes. These cells are known as T- lymphocytes (T-cells). Certain CMI responses influence and regulate the activities of AMI and inflammation by producing and releasing cytokines. For total immunocompetence, CMI must function optimally. Cytokines are small proteins produced by WBCs and other cells. Cytokines have effects on cells of the immune system and on other body cells. 1. Cytokines act like messenger that tell specific cells how and when to respond. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  16 2. Cytokines include the interleukins, interferons, colony- stimulating factors, and tumor necrosis factor. 3. See table 2 for the activity of selected cytokines See table 3 for the comparison of humoral and cell-mediated immunity Table 2. Activity of Selected Cytokines CYTOKINE ACTIONS Pro-Inflammatory Cytokines Interleukin-1 (IL-1) Induces fever Stimulates production of prostaglandins Increases growth of CD4+ T-cells Interleukin-2 (IL-2) Increases growth and differentiation of T- lymphocytes Enhances natural killer cell activity against cancer cells Interleukin-6 (IL-6) Stimulates liver to produce fibrinogen and protein C Increases rate of bone marrow production of stem cells Increases numbers of sensitized B-lymphocytes Tumor Necrosis Factor Induces fever (TNF) Major cytokine involved in rheumatoid arthritis damage Major cytokine involved in the acute inflammatory response to infectious bacteria and starts many of the systematic complication of severe infection or sepsis Participates in graft rejection Induces cell death Stimulates delayed hypersensitivity reactions and allergy Growth Factors Granulocyte colony- Increases numbers and maturity of neutrophils stimulating factor (G-CSF) Granulocyte-macrophage Increases growth and maturation of myeloid stem cells colony-stimulating factor (GM-CSF) Erythropoietin Increases growth and differentiation of erythrocytes Thrombopoietin Increases growth and differentiation of platelets Table 3. Comparison of Humoral and Cell-Mediated Immunity Characteristics Humoral Immunity Cell-Mediated Immunity Cells Involved B lymphocytes T lymphocytes, macrophages Products Antibodies Sensitized T cells, cytokines Memory Cells Present Present Protection Bacteria Fungus Viruses (extracellular) Viruses (intracellular) Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  17 Respiratory and GI pathogens Chronic Infectious agents Tumor cells Examples Anaphylactic shock Tuberculosis Atopic diseases Fungal infections Transfusion reaction Contact dermatitis Bacterial infections Graft rejection Destruction of cancer cells Four T-lymphocytes subsets that are critically important for the development and continuation of CMI are: 1. Helper-inducer T-cells (T4 cells, TH cells, CD4+ cells) easily recognize self cells versus non-self cells. In response to the recognition of non-self (antigen), helper-inducer T- cells secrete cytokines that can enhance the activity of other WBCs. 2. Suppressor T-cells (T8 cells, CD8+ cells, TS cells) regulate CMI by preventing hypersensitivity (continuous overreactions) when a person is exposed to non-self cells or proteins. These cells secrete cytokines that inhibit immune-system cell action and work in opposition to helper-inducer T-cells. Immune function is well balanced when T4+ cells outnumbered T8+ cells by a 2:1 ratio. 3. Cytotoxic or cytolytic T-cells are a subset of suppressor cells that destroy cells containing a processed antigen’s major histocompatibility complex (MHC). This activity is most effective against self cells infected by parasites, such as viruses or protozoa. 4. NK cells (CD16 cells) have direct cytotoxic effects on some non-self cells that are independent of the interactions of other WBCs. NK cells conduct “seek and destroy” missions in the body to eliminate non-self cells. NK cells are most effective in destroying unhealthy or abnormal self cells, such as cancer cells and virally infected body cells. CMI helps protect the body through the ability to differentiate self from non-self. The non-self cells most easily recognized by CMI are cancer cells. Self cells infected by organisms that live within host cells and transformed cancer cells are generally recognized as abnormal ad are destroyed by CMI. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  18 PRETEST Before you start our first lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Infectious Process. Write your answer in a piece of paper. Good luck. Be honest to yourself. Matching Type: Match Column A to Column B. Good luck COLUMN A COLUMN B Infection Protein molecules released by bacteria to affect host cells at a distant site Pathogen Skin infections, pneumonia Virulence Urinary tract infections, peritonitis, hemolytic- uremic syndrome Normal flora Invasion of a body tissue by microorganisms that allows replication of the microorganisms and results in tissue damage Colonization Warts Toxins Any microorganism capable of producing disease Microorganisms Syphilis Helicobacter pylori Peptic ulcers and gastritis Staphylococcus aureus Parasites that live at the host’s expense Corynebacterium diphtheriae The ability of a pathogen to invade the body and Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  19 cause damage and the frequency with which it causes disease Treponema pallidum The process of having pathogenic organisms living and growing in or on a body area without causing disease or damage Escherichia coli Microorganisms that live in or on the human host without causing disease Papillomavirus Diphtheria “Our greatest weakness lies in giving up. The most certain way to succeed is always to try just one more time.” -Thomas A. Edison “You’ve got to get up every morning with determination if you’re going to go to bed with satisfaction.” -George Lorimer Lesson 2 The Infectious Process OVERVIEW An infection is the invasion of a body tissue by microorganisms that allows replication of the microorganisms and results in tissue damage. A pathogen is any microorganism, also called an agent, capable of producing disease. See table 4 for lists of disease-causing pathogens. Infection can be divided into localized, disseminated and systemic disease. o Localized- limited to small area. o Disseminated- has spread to areas of the body beyond the initial site of infection. o Systemic- have spread extensively throughout the body, often via the blood. Virulence is the ability of a pathogen to invade the body and cause damage and the frequency with which it causes disease. Normal flora are microorganisms that live in or on the human host without causing disease. Some beneficial microbes can be pathologic when they move to another body area. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  20 Colonization is the process of having pathogenic organisms living and growing in or on a body area without causing disease or damage. Toxins are protein molecules released by bacteria to affect host cells at a distant site. 1. Exotoxins are released by the bacteria into the host’s body. 2. Endotoxins remain within the bacteria cell walls and are released when the bacterium is attacked. Microorganisms are parasites that live at the host’s expense. Infectious disease can be communicable (transmitted from person to person, such as influenza) or not communicable (e.g., peritonitis). Table 4. Lists of Disease-Causing Pathogens Table 4.A. Disease-Causing Bacteria Bacteria Diseases caused Clostridia Clostridium botulinum Food poisoning with progressive muscle Clostridium tetani paralysis Tetanus (lockjaw) Corynebacterium diphtheriae Diphtheria Escherichia coli Urinary tract infections, peritonitis, hemolytic- uremic syndrome Haemophilus Haemophilus influenza Nasopharyngitis, meningitis, pneumonia Haemophilus pertussis Pertussis (whooping cough) Helicobacter pylori Peptic ulcers, gastritis Klebsiella-Enterobacter organisms Urinary tract infections, peritonitis, pneumonia Legionella pneumophila Pneumonia (Legionnaires’ disease) Mycobacteria Mycobacterium leprae Hansen’s disease (leprosy) Mycobacterium Tuberculosis tuberculosis Neisseriae Neisseria gonorrhoeae Gonorrhea, pelvic inflammatory disease Neisseria meningitidis Meningococcemia, meningitis Proteus species Urinary tract infections, peritonitis Pseudomonas aeruginosa Urinary tract infections, meningitis Salmonella Salmonella typhi Typhoid fever Other Salmonella Food poisoning, gastroenteritis organisms Shigella Shigellosis; diarrhea, abdominal pain, and fever (dysentery) Staphylococcus aureus Skin infections, pneumonia, urinary tract infections, acute osteomyelitis, toxic shock syndrome Streptococci Streptococcus faecalis Genitourinary infection, infection of surgical wounds Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  21 Streptococcus pneumonia Pneumococcal pneumonia Streptococcus pyogenes (group A β-hemolytic Pharyngitis, scarlet fever, rheumatic fever, streptococci) acute glomerulonephritis, erysipelas, S. pyogenes (group B β- pneumonia hemolytic streptococci) Streptococcus viridans Urinary tract infections Bacterial endocarditis Treponema pallidum Syphilis Table 4.B. Disease-Causing Viruses Virus Diseases caused Adenoviruses Upper respiratory tract infection, pneumonia Arbovirus Syndrome of fever, malaise, headache, myalgia; aseptic meningitis; encephalitis Coronavirus Upper respiratory tract infection Coxsackieviruses A and B Upper respiratory tract infection, gastroenteritis, acute myocarditis, aseptic meningitis Echoviruses Upper respiratory tract infection, gastroenteritis, aseptic meningitis Hepatitis A, B, C Viral hepatitis Herpesviruses Cytomegalovirus (CMV) Gastroenteritis; pneumonia and retinal damage in immunosuppressed individuals, infectious mononucleosis– like syndrome Epstein-Barr Mononucleosis, Burkitt’s lymphoma (possibly) Herpes simplex type 1 Herpes labialis (“fever blisters”), genital herpes infection Herpes simplex type 2 Genital herpes infection Varicella-zoster Chickenpox, shingles Human immunodeficiency HIV infection, AIDS virus (HIV) Influenza A and B Upper respiratory tract infection, H1N1 (swine) flu, avian (bird) flu Mumps Parotitis, orchitis in postpubertal males Papillomavirus Warts Parainfluenza 1-4 Upper respiratory tract infection Parvovirus Gastroenteritis Poliovirus Poliomyelitis Pox viruses Smallpox Reoviruses 1, 2, 3 Upper respiratory tract infection Respiratory syncytial virus Gastroenteritis, respiratory tract infection Rhabdovirus Rabies Rhinovirus Upper respiratory tract infection, pneumonia Rotaviruses Gastroenteritis Rubella German measles Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  22 Rubeola Measles West Nile virus Flulike symptoms, meningitis, encephalitis Table 4.C. Disease-Causing Fungi Fungi Diseases caused Organs Affected Aspergillus fumigatus Aspergillosis Lungs Otomycosis Ears Blastomyces dermatitidis Blastomycosis Lungs, various organs Candida albicans Candidiasis Intestines Vaginitis Vagina Thrush Skin,† mouth Coccidioides immitis Coccidioidomycosis Lungs Pneumocystis jiroveci Pneumocystis pneumonia (PCP) Lungs Sporothrix schenckii Sporotrichosis Skin, lymph vessels Trichophyton Tinea pedis Skin† Microsporum Tinea capitis Skin† Epidermophyton Tinea corporis Skin† Transmission of infection requires these factors: 1. Reservoir (or source) of infectious agents a. Animate reservoirs include people, animals, and insects b. Inanimate reservoirs include soil, water, other environmental sources, or medical equipment 2. Susceptible hosts with a portal of entry 3. Mode of transmission 4. Portal of exit (exit of the microbe from the host often occurs through portal of entry but can exit by other routes) Prevention of infection transmission involves disrupting the three factors or breaking the chain of infection at any point. Host factors that increase the susceptibility to infection are: 1. Congenital or acquired immune deficiencies 2. Alteration of normal flora by antibiotic therapy 3. Age: infants and over 65 years 4. Hormonal changes (e.g., pregnancy, diabetes, corticosteroid therapy, or adrenal insufficiency) 5. Defective phagocytosis 6. Breaks in skin or mucous membranes 7. Interference with flow of urine, tears, or saliva 8. Impaired cough reflex or ciliary action 9. Malnutrition od dehydration 10. Smoking, alcohol consumption, or inhalation f toxic chemicals 11. Invasive therapy, chemotherapy, radiation therapy, steroid therapy, or surgery Routes of transmission are: 1. Respiratory tract 2. Gastrointestinal tract Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  23 3. Genitourinary tract Common modes of infection transmission are: 1. Contact transmission (most common) a. Direct (person-person) contact, in which the source and host have physical contact and microorganisms are transferred directly (e.g., common colds) b. Indirect contact, in which the transfer of microorganism occurs from a source to a host by passive transfer from a contaminated object (e.g., staphylococcal organisms) 2. Droplet transmission from contact with infected secretions or droplets (e.g., influenza) 3. Airborne transmission from small airborne particles containing pathogens that leave the infected source , are suspended in the air, and enter a susceptible host (e.g., Mycobacterium tuberculosis or the varicella zoster virus) 4. Vector transmission, in which insects carry pathogens between two or more hosts, such as the deer tick that causes Lyme disease Human physiologic defenses against infection include: 1. Intact skin and mucous membranes 2. Normal flora 3. Secretions of respiratory, GI, and genitourinary tracts 4. Inflammation or phagocytosis (native immunity) 5. Antibody-mediated immunity (AMI) and Cell-mediated immunity (CMI) A hospital-acquired infection (HAI) is an infection acquired while the patient was in a health care setting. Old terms for this include nosocomial and iatrogenic. ▪ Infection control and prevention are interprofessional efforts. This include: o Health organization-specific and department-specific infection control policies and procedures o Surveillance and analysis o Patient and staff education o Community and interprofessional collaboration o Product evaluation with an emphasis on quality and cost savings o Bioengineering for designing health care facilities that help control the spread of infections. HAIs can be prevented or controlled in at least five major ways: 1. Hand hygiene- refers to both handwashing and alcohol-based hand rubs (ABHRs). a. Hand hygiene (wetting, soaping, lathering, applying friction under running water for at least 15 seconds, rinsing, and adequate drying). For recommendations in best practices in hand washing, read chart 1. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  24 b. ABHRs- allows healthcare provider to have more time to render care because of reduced time in seeking sinks. But health care providers should bear in mind that ABHRs have also limitation. Chart 1. Hand Hygiene Recommendations from CDC When hands are visibly soiled or contaminated with proteinaceous material or visibly soiled with blood or other body fluids, wash hands with soap and water. If hands are not visibly soiled, use an alcohol-based hand rub (ABHR) for decontaminating hands or wash hands with soap and water. Use either ABHR or wash with soap and water (decontaminate hands) before having direct 882 contact with patients. Decontaminate hands before donning sterile gloves to perform a procedure such as inserting an invasive device (e.g., indwelling urinary catheter). Decontaminate hands after contact with a patient's intact skin (e.g., taking a pulse) or with body fluids or excretions/secretions. Decontaminate hands after removing gloves. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. ACTION ALERT NURSING SAFETY PRIORITY If your hands are visibly dirty or soiled or feel sticky or if you have just toileted, wash your hands instead of using ABHRs. Keep in mind that ABHRs are also ineffective against spore-forming organisms such as Clostridium difficile, a common cause of health care–associated diarrhea, especially in older adults. Do not use an ABHR before inserting eyedrops, ointments, or contact lenses because alcohol can irritate the patient's eyes, causing burning and redness. The Joint Commission's National Patient Safety Goals require that health care agencies monitor handwashing practices and the use of ABHRs to make sure that HCWs are performing hand hygiene on a regular basis. The CDC recommends using antiseptic solutions such as chlorhexidine for handwashing in caring for patients who are at high risk for infection (e.g., those with impaired IMMUNITY). 2. Disinfection/sterilization a. Sterilization- destroying all living organisms and bacterial spores. This process is used in many invasive procedures where it requires sterile technique such as insertion of vascular access devices (VADs). b. Disinfection-does not kill spores and only ensure reduction in the level of disease-causing organisms. High-level disinfection is done when an item will go inside the body of Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  25 the patient where there is a normal flora or resident bacteria (example: GI and respiratory tracts). 3. Standard precautions- are based on the belief that all body excretions, secretions, and moist membranes and tissues, excluding perspiration, are potentially infectious. As barriers to potential or actual infections, personal protective equipment (PPE) is used. PPE refers to gloves, isolation gowns, face protection (masks, goggles, face shields), and powered air- purifying respirators (PAPRs) or N95 respirators. See figure 2 for the example of PPE and PAPRs. 4. Transmission –based precautions- also known as Isolation Precautions. 5. Staff and patient placement and cohorting a. Adequate staffing will help prevent infection. b. Patient placement was used to reduce the spread of infection. c. Cohorting is the practice of grouping patients who are colonized or infected with the same pathogen. It has been used the most with patients who have an outbreak of a multidrug-resistant organism such as methicillin-resistant Staphylococcus aureus (MRSA). It is particularly effective in long-term care settings. Figure 2. A. Nurse in personal protective equipment (PPE) caring for a patient in a private room. B. Powered air-purifying respirator (PAPR). A B Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  26 Infection control within a health care QUALITY IMPROVEMENT facility is designed to reduce the risk for HAIs and thus reduce morbidity and mortality. Participation in care processes and monitoring methods to design a test changes that reduce HAIs is an essential component of nursing practice. An example of this is using a screening checklist for patients who have Foley catheter to minimize urinary infection. The checklist may include the following: 1. Catheter was secured 2. Tamper-evident seal was intact 3. Catheter tubing was not twisted or had a dependent loop 4. Catheter bag was positioned lower than the bladder level 5. Drainage bag did not touch the floor or was not overfilled. Centers for Disease Control and Prevention (CDC) Transmission-Based Guidelines include implementing: 1. Standard precautions assume that all body excretions, secretions and moist membranes and tissues, excluding perspiration, are potentially infectious; the precautions should be used in the care of all patients. a. Respiratory hygiene and cough etiquette (RH/CE) for respiratory illnesses (1) Patient, staff, and visitor education (2) Posted signs (3) Hand hygiene ACTION ALERT NURSING SAFETY PRIORITY Remember that gloves are an essential part of infection control and should always be worn as part of standard precautions. Either handwashing or use of alcohol-based hand rubs is done before donning and after removing gloves is the most effective strategy for preventing infection transmission. (4) Covering the nose and mouth with tissue and prompt tissue disposal or using surgical masks (5) Separation from the person with respiratory infection by more than 3 feet (1 m) (6) Safe injection practices, using a sterile, single-use disposable needle and syringe for each injection, prevention of contamination of injection equipment and drug, and use of retractable needles 2. Transmission-based precautions a. Airborne precautions for patients known or suspected to have infections transmitted by the airborne transmission route. These infections are caused by organisms that can be suspended in air Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  27 for prolonged periods. Examples are tuberculosis, measles [rubeola], and chickenpox [varicella]). To prevent airborne spread of microbes, use: (1) Negative airflow rooms (2) Enclosed booths with high-efficiency particulate air (HEPA) filtration or ultraviolet light b. Droplet precautions for patients known or suspected to have infections transmitted by the droplet transmission route. These infections are caused by organisms in droplets that may travel 3 feet but not suspended for long periods. Examples are influenza, mumps, pertussis, and meningitis caused by either Neisseria meningitides or Haemophilus influenza type B. c. Contact precautions for patient known or suspected to have infections transmitted by direct contact or contact with items in the environment Examples are significant multidrug-resistant organism [MDRO] infection or colonization, pediculosis, scabies, respiratory syncytial virus [RSV}, and Clostridium difficile. A number of microorganisms have become resistant to multiple antibiotics, and once-useful drug no longer control these infectious agents, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). ACTION ALERT NURSING SAFETY PRIORITY Patients most at risk for hospital acquired multidrug-resistant organism (MDRO) infections are older adults ad those who have suppressed immunity, have a log history of antibiotic therapy. Or have invasive tubes or lines. Intensive care unit (ICU) patients are especially at risk. Check with your agency policy regarding specific infection-prevention measures. Example includes bathing patient with chlorhexidine clothes. Complications from infection are relapse, cellulitis, pneumonia, abscess formation, sepsis, septic shock, disseminated intravascular coagulation (DIC), multi-system organ failure, and death. NURSING ASSESSMENT Obtain patient information about: 1. Age 2. History of tobacco or alcohol use 3. Current illness or disease (e.g., diabetes) 4. Past and current drug use (e.g., prescribed, OTC, recreational, injection) Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  28 5. Nutritional status 6. Previous vaccination or immunization 7. Exposure to infectious agents 8. Contact with animal, including pets 9. Insect bites 10. Travel history 11. Sexual history 12. Transfusion history 13. Previous infection history 14. Order of symptom onset Assess for and document: 1. Skin manifestation a. Redness b. Warmth c. Swelling d. Drainage or pus e. Pain 2. Generalized manifestations a. Fever (usually a temperature above 101  F [ 38C] or 99 F [37C) for older adults b. Chills c. Malaise and fatigue d. Lymphadenopathy e. Joint pain, muscle aches f. Photophobia 3. GI tract manifestations a. Nausea and vomiting b. Diarrhea 4. Genitourinary manifestations a. Dysuria b. Frequency c. Urgency d. Hematuria e. Purulent discharges f. Pelvic, flank, and low back pain 5. Respiratory tract manifestations a. Cough b. Congestion c. Rhinorrhea, sputum d. Sore throat e. Chest pain 6. Psychosocial manifestations a. Anxiety- assess level of understanding b. Malaise and fatigue- assess the current level of activity c. Stress d. Fear Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  29 e. Isolation or guilt 7. Abnormal laboratory findings a. Positive culture b. Positive serologic results c. High or low WBC count d. Elevated erythrocyte sedimentation rate (ESR) 8. Abnormal imaging findings a. Chest x-ray, sinus or joint films, GI studies b. Computed tomography (CT) c. Magnetic resonance imaging (MRI) d. Ultrasonography 9. Biopsy NURSING DIAGNOSIS Hyperthermia related to triggered immune response by pathogen. PLANNING AND IMPLEMENTATION Effective anti-infective therapy requires: 1. Agent appropriate for the know organism. 2. Sufficient dosage and duration of treatment. 3. Timely administration (avoid delayed or skipped doses). ACTION ALERT NURSING SAFETY PRIORITY Before administering an antimicrobial drug, check to see that the patient is not allergic to it. Be sure to take an accurate allergy history before drug therapy begins to prevent possible life-threatening reactions, such as anaphylaxis! Nursing interventions include: 1. Obtaining and reviewing an allergy history before giving antibiotics 2. Monitoring the patient for side effects of antibiotics, such as nausea, vomiting, or rash 3. Using best practices to reduce fever; this can vary by age, underlying pathology, or institutional policy a. Antipyretics b. External cooling measures but avoid shivering 4. Monitoring for the manifestations of dehydration a. Thirst b. Decreased skin turgor c. Dry skin and mucous membrane 5. Encouraging fluid intake or administering IV fluids 6. Measuring intake and output Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  30 7. Monitoring vital signs and oxygen saturation 8. Monitoring skin intactness, color, and temperature EVIDENCE-BASED PRACTICE Fever may increase the potential for pressure ulcer formation. Monitor the patient more often and provide pressure-relieving interventions for vulnerable patients. 9. Assessing level of consciousness and for seizure activity 10. Monitoring laboratory values 11. Providing or assisting with oral and personal hygiene 12. Teaching the patient and family about the mode of transmission of infection and mechanism that prevent spread to others Community-Based Care Provide vaccinations, using guidelines established annually by the CDC. Remove indwelling urinary catheters as soon as possible to prevent urinary tract infections. Emphasize the importance of clean home environment, especially for the patient who is immunocompromised or uniquely susceptible to superinfection. Demonstrate proper handwashing with patient and family and ask for a return demonstration to assess learning. Teach the patent and family about: 1. What is causing illness 2. Modes of transmission if applicable 3. Specific precautions for transmission prevention, including: a. Whether special household cleaning is necessary and if so, what those special steps include b. How to dispose of any used needles and syringes safely and legally c. Cleaning clothing soiled with blood or other body fluids by washing them with bleach or disinfectant (e.g., Lysol) d. Cleaning measures based on actual equipment and facilities 4. The importance of adhering to the prescribed antibiotic therapy regimen, including: a. Timing of doses b. Number of days c. Any specific drug administration instructions (e.g., before meals, with meals, without other agents) and the possible side effects d. Allergic manifestations and the need to notify a health care provider if an adverse reaction occurs Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  31 e. What to do if a drug dose is missed (e.g., doubling the dosage or waiting until the next dose time) 5. Managing IV drug therapy Refer to home health care agencies as needed Health Promotion and Maintenance Most commonly affected patients with infections are the vulnerable groups of older adults and those who have altered immune system or immunocompromised people. Appropriate interventions and early detection of signs and symptoms may reduce the possibility of infection. Chart 2 summarizes the nursing interventions for infection prevention and control. Chart 2. Nursing Interventions for Patients who are at Risk for Infection Assess patients for risk for infections. Monitor for signs and symptoms of infection. Monitor laboratory tests results such as cultures and white blood cell (WBC) count and differential. Screen all visitors for infections or infectious disease. Inspect skin and mucous membranes for redness, heat, pain, swelling, and drainage. Promote sufficient nutritional intake, especially protein for healing. Encourage fluid intake to treat fever. Teach the patient and family the signs and symptoms of infections and when to report them to the primary health care provider. Teach the patient and family how to avoid infections in health care agencies and the community. EVALUATION: Expected Patient Outcomes The expected outcomes include that the patient: 1. Has body temperature and other vital signs within baseline 2. Adheres to drug therapy regimen Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  32 PRETEST Before you start our first lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Infectious Process. Write your answer in a piece of paper. Good luck. Be honest to yourself. Identification: Identify what is being asked in the following sentences. _________1. It is an excess of fluid in the lungs resulting from an inflammatory process. _________2. It is highly communicable disease caused by Mycobacterium tuberculosis infection. _________3. It is a deadly disease with occasional outbreaks that occur primarily on the African continent. _________4. It is the widespread inflammation of liver cells, resulting in enlargement of the liver and congestion with inflammatory cells. _________5. It is an acute inflammatory demyelinating polyneuropathy (also called polyradiculoneuropathy) that affects the peripheral nervous system axons and myelin, causing motor weakness and sensory abnormalities. Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  33 _________6. It is an intracellular bacterium that causes genital chlamydial infection, which is the most common sexually transmitted disease (STD) in the United States. _________7. It is a sexually transmitted bacterial infection caused by Neisseria gonorrhoeae, a gram-negative intracellular diplococcus. It is transmitted by direct sexual contact with mucosal surfaces (vaginal intercourse, orogenital contact, or anogenital contact). _________8. It is an acute, recurring, incurable viral disease. _________9. It is spread by the fecal-oral route, consuming contaminated food, or by person-to-person contact (e.g. oral-anal sexual activity). _________10. It is transmitted through broken skin or mucous membranes by infected blood and serous fluids. “You cannot change your future, but you can change your habits, and surely your habits will change your future.” -A.P.J. Abdul Kalam “Start by doing what’s necessary; then do what’s possible; and suddenly you are doing the impossible.” -Francis of Assisi Lesson 3 Responses to Alterations: INFECTIOUS DISORDERS OF ADULTS A. PNEUMONIA Overview Pneumonia is an excess of fluid in the lungs resulting from an inflammatory process. It can be caused by many infectious organisms and by inhalation of irritating agents or aspiration of stomach contents. Infectious pneumonias are categorized as community- acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP), health care- acquired pneumonia (HCAP), and ventilator-associated pneumonia (VAP). Inflammation and infection in the lungs result in local capillary leak, edema, and exudate that reduce gas exchange and lead to hypoxemia, Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  34 interfering with oxygenation and tissue perfusion and possibly leading to death. Risk factors for pneumonia include: 1. Being an older adult 2. The presence of a chronic health problem, particularly a respiratory problem or condition that is associated with immunosuppression. 3. Recent exposure to respiratory viral or influenza infections NURSING ASSESSMENT Obtain patient information about: 1. Age 2. Living, work, and school environments, including exposure to droplet-based infection 3. Diet, exercise, and sleep routines 4. Swallowing problems or presence of oral or nasogastric (NG) tubes that may result in aspiration 5. Tobacco and alcohol use 6. Past and current use of drugs, including drug addiction or injection drug use 7. Acute or chronic respiratory problems 8. Recent skin rashes, insect bites, or exposure to animals 9. Home respiratory equipment use and cleaning 10. Date of last influenza or pneumococcal vaccine Assess for and document: 1. General appearance 2. Oxygen saturation 3. Abnormal lung sounds, particularly crackles, rhonchi, and wheezing 4. Increased effort of breathing, especially dyspnea, tachypnea, and use of accessory muscles 5. Chest or pleuritic pain or discomfort 6. Fever, chills, and fatigue 7. Cough and mucus or sputum production 8. Tachycardia, hypotension 9. Mental status changes (especially in an older adult) For older adults, you should consider the following: 1. The most common manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever or cough. 2. Diagnosis is based on manifestations, sputum gram stain or culture, elevated WBC count, chest x-ray, peripheral oxygenation (SPO2), and arterial blood gas (ABG) levels. PLANNING AND IMPLEMENTATION 1. Depends on the priority nursing problems. a. Hypoxemia and potential for airway obstruction: Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  35 i. Monitor rate, rhythm, depth, and effort of ventilation. ii. Assess pulse oximetry and administer oxygen by nasal cannula or mask as prescribed. iii. Instruct the patient on cough and deep-breathing technique or the correct use of incentive spirometry (sustained maximal inspiration) and encourage him or her to perform 5 to 10 breaths per session every hour while awake. iv. Assess the patient’s ability to cough effectively. v. Monitor fluid intake and encourage the alert patient to maintain sufficient intake to provide a dilute urine output. vi. Administer prescribed bronchodilators and corticosteroids by aerosol nebulizer or by metered dose inhaler. vii. Monitor for complications such as hypoxemia, ventilator failure, atelectasis, pleural effusion, and pleurisy. b. Potential for sepsis: i. Administer prescribed anti-infective therapy based on organism sensitivity. ii. For pneumonia resulting from aspiration of food or stomach contents, steroids and NSAIDs are used with antibiotics to reduce the inflammatory response. 2. Teach the patient about the following (community-based care): a. The importance of completing the full course of antibiotic therapy b. Notifying the health care provider if chills, fever, persistent cough, dyspnea, wheezing, hemoptysis, increased sputum production, chest discomfort, or increasing fatigue recurs or if symptoms fail to resolve. c. The importance of getting plenty of rest and gradually increasing exercise. d. Preventing upper respiratory tract infections and viruses by: i. Using handwashing ii. Avoiding crowds and people who have a cold or flu iii. Avoiding exposure to irritants such as smoke iv. Obtaining the pneumococcal vaccination 3. Encourage the patient to quit smoking, and provide information on smoking cessation. EVIDENCE-BASED PRACTICE Three care actions, known as a ventilator bundle, have been shown to Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  36 reduce the incidence of VAP: hand hygiene, oral care to decontaminate the mouth, and elevation of the head of the bed. 4. Implement these practices for the intubated patient to reduce VAP: a. Wash hands before and after contact with the patient. b. If possible, use a disinfecting oral rinse immediately before the intubation. c. Provide oral care with a disinfecting mouthwash every 12 hours. d. Remove subglottic secretions; this can be done continuously if the endotracheal tube has a separate lumen that opens directly above the tube cuff. e. Keep the head of the bed elevated 30 to 45 degrees. f. Use best practices to promote weaning from the mechanical ventilator as soon as feasible. B. TUBERCULOSIS Overview Pulmonary tuberculosis (TB) is a highly communicable disease caused by Mycobacterium tuberculosis infection. The organism is transmitted by aerosolization (airborne route) from an infected person during coughing, laughing, sneezing, whistling, or singing. When the bacillus is inhaled into a susceptible site, it multiplies freely, causing an exudative pneumonitis. While exposure may lead to infection, few people manifest active TB after exposure to the organism. Initial infection is seen more often in the middle or lower lobes of the lung, and re-activation occurs more in the upper lobes. Progression of infection leads to an inflammatory lump that surrounds the bacilli and is filled with collagen, fibroblasts, and lymphocytes. The lump necroses, causing calcification or liquefaction and leading to destruction of lung tissue with cavity formation. Miliary, or hematogenous, TB is the spread of TB throughout the body when a large number of organisms enter the blood and can then infect the brain, liver, kidney, or bone marrow. An infected individual is not infectious to others until manifestations of disease occur. People at greatest risk for developing TB are: 1. Those in constant, frequent contact with an untreated individual with active TB. 2. Those who have decreased immune function 3. Those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities 4. Older homeless people Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  37 5. Abusers of injection drugs or alcohol 6. Members of lower socioeconomic groups 7. Foreign immigrants (especially from Mexico, the Philippines, and Vietnam). NURSING ASSESSMENT Obtain patient information about: 1. Persistent cough 2. Weight loss 3. Anorexia 4. Night sweats 5. Fever or chills 6. Dyspnea or hemoptysis 7. Past exposure to TB 8. Country of origin and travel to foreign countries 9. History of bacillus Calmette-Guerin (BCG) vaccination Assess for and document: 1. Dullness with percussion over involved lung fields 2. Bronchial breath sounds 3. Crackles, wheezes 4. Enlarged lymph nodes TB is diagnosed on the basis of manifestations and/or a positive nucleic acid amplification test (NAAT). Blood analysis by an enzyme- linked immunosorbent assay using the QuantiFERON-TB Gold (QFT-G) may be used for testing in the acute care setting. A purified protein derivative (PPD) two-step test may be used for screening purposes. ACTION ALERT NURSING SAFETY PRIORITY Do not assume that a positive PPD reaction of 10 mm induration 48 to 72 hours after injection means that active disease is present. It only indicates exposure to TB, TB vaccination, or the presence of inactive (dormant) disease. A reduced PPD skin reaction or a negative PPD skin test result does not rule out TB disease or infection in the very old or in anyone who is severely immunocompromised. PLANNING AND IMPLEMENTATION 1. Combination drug therapy is the most effective method of treating TB and preventing transmission. Current first-line therapy uses four medications. a. Isoniazid (INH) for 6 months b. Rifampin for 6 months c. Pyrazinamide for the first 2 months Module II- NUPC 113: Care of Clients with Problem in Infectious, Inflammatory and Immunologic Response DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  38 d. Ethambutol for 6 months DRUG ALERT NURSING SAFETY PRIORITY The first-line drugs used as therapy for tuberculosis all can damage the liver. Warn the patient to not drink any alcoholic beverages for the entire duration of TB therapy. Duration of therapy is usually 6 months but can be as long as 2 years