COMMUNICABLE DISEASES Diseases caused by pathogenic microorganisms, which can be transmitted from an infected person to a susceptible person by direct, indirect mean means s or thro throug ugh h a brea break k in skin skin integrity
Horizontal Transmission Transmission Manner of transfer of microorganisms is in a horizontal position Vertical Transmission Manner in which which microorg microorganis anisms ms are Manner transf transferr erred ed is in a vertic vertical al manne mannerr – from up going down Example: o Infe Infect cted ed moth mother er to newb newbor orn n child transmission
Communicable Communicable Diseases are transmitted through: 1. Direct Mode of Transmission A person to person transmission Most common is thr through ugh Dro Droplet plet Mos transmission Examples: o Kissing o Sexual Contact Happens in humans 2. Indirect Mode of Transmission From a sour source ce of tran transm smis issi sion on to a From new host with intermediary intermediary object A bridge connects you to an infected person Bridges or intermediate objects Examples: o Vehicle-borne Transmission Transmission Non-living things Articl Articles es used used by patien patientt like like cath cathet eter er,, tubi tubing ngs, s, linens Transmission Vector-borne Transmission Living things but are non human Insects, arthropods, rodents 3. Break in Skin Transmission Inoculation Contaminated sharps or needles Animal Bites 4. Airborne Transmission Microorganisms are suspended in air Microorganisms There is no limitation to the distance traveled by microorganism microorganism Different from Droplet transmission Microorganism remains on surface Travel is limited to a maximum distance of three (3) feet. Concept: these modes modes are class classifi ified ed under under All these Horizontal Transmission
Infectious Diseases Diseases wherein there is a presence of a living microorganism in the body, which may not be transmitted through ordinary contact Need Need not not be tran transf sfer erre red d from from one one person to another Contagious Diseases that Diseases transmitted
can
easily
be
Concepts: communicable diseases are All infectious but not contagious Becaus use e ther there e is the the pres presen ence ce of a Beca living microorganism Because not all of the microorganisms can be easily e asily transmitted All contagious diseases are infectious contagious diseases are All communicable diseases Diphtheria is a disease, which is o Contagious o Communicable o Infectious Malaria is a disease, which is o Communicable o Infectious o But not contagious Tetanus is a disease, which is o Infectious only Epidemiological Triad Three (3) factors for a disease to take place 1. HOST A person An animal Concept: Consider the susceptibility of the host Susceptibility o Pertains to degree of resistance 1
Pathogenicity Pathogenicity of microorganisms Capacity Capacity of microorg microorganis anisms ms to cause cause infection
If resistance is low, susceptible person is prone to infection
Types of Hosts: 1.1) Patient person n infect infected ed manif manifest esting ing signs signs A perso and symptoms 1.2) Carrier who harbors Individual micro microorg organi anisms sms but but shows shows no signs signs and symptoms 1.3) Suspect Individuall whose whose medical medical history history and Individua sympto symptoms ms sugge suggests sts that that he may be developing a specific infection Signs and symptoms are suggestive 1.4) Contact who come in close Individuals association or in contact or exposed to infected person
Two Two (2) (2) most ost comm common on micr microo oorg rgan anis isms ms causing infections Bacteria Viruses Bacteria multiply in both both living living and nonnon Can multiply living things Cannot pass through filters in the body because they are big Therefore, it is okay to have bacterial infe infect ctio ion n even even duri during ng preg pregna nanc ncy, y, except for Treponema pallidum, which passes passes through through the placenta placentall barrier barrier th after the 16 week of pregnancy. fatal in the first Syphilis is not trimester Syphilis is fatal in the third trimester Anti-bac acter terial ial medic medicati ations ons give give only only Anti-b temporary immunity Viruses Can only multiply in living things Reservoir is a living thing Can pass through the body filters: o Blood Brain Barrier o Placental Barrier self-limiting diseases It gives rise to self-limiting Viral infections have own time frame Example: o Col Colds las last for 2-3 2-3 days ays with ith watery secretions as symptoms After this, this, complicat complications ions would be the one present with yellowish or mucoid discharges probably indicative of sinusitis o Infl Influe uenz nza a is pres presen entt for for one one week After one week, pneumonia sets in. management for viral Medical infections: o Treated symptomatically not by anti-viral agents o Antibiotics may be used to treat secondary bacterial infections o Purp Pu rpos ose e is to incr increa ease se body body resistance
Concepts: The PA PATI TIEN ENT T is the the leas leastt sour source ce of The infection The PATIENT has the least chance to spread microorganisms o Because he manifests signs and symptoms of the disease, he is isolated o Prec Precau auti tion onar ary y meas measur ures es are are now taken The CARRIER has the highest potential to spread infection o Becaus Because e he does does not manife manifest st sign igns and symp ymptom toms of the the disease o However, he has the microorganisms 2. AGENT Microorganisms They y have have the the high highes estt popu popula lati tion on The among all living things all are susceptible to Not microorganisms microorganisms are virulent Not all microorganisms Concepts: Virulence Strength and power of microorganisms to cause infection
3. ENVIRONMENT 2
Pathogenicity Pathogenicity of microorganisms Capacity Capacity of microorg microorganis anisms ms to cause cause infection
If resistance is low, susceptible person is prone to infection
Types of Hosts: 1.1) Patient person n infect infected ed manif manifest esting ing signs signs A perso and symptoms 1.2) Carrier who harbors Individual micro microorg organi anisms sms but but shows shows no signs signs and symptoms 1.3) Suspect Individuall whose whose medical medical history history and Individua sympto symptoms ms sugge suggests sts that that he may be developing a specific infection Signs and symptoms are suggestive 1.4) Contact who come in close Individuals association or in contact or exposed to infected person
Two Two (2) (2) most ost comm common on micr microo oorg rgan anis isms ms causing infections Bacteria Viruses Bacteria multiply in both both living living and nonnon Can multiply living things Cannot pass through filters in the body because they are big Therefore, it is okay to have bacterial infe infect ctio ion n even even duri during ng preg pregna nanc ncy, y, except for Treponema pallidum, which passes passes through through the placenta placentall barrier barrier th after the 16 week of pregnancy. fatal in the first Syphilis is not trimester Syphilis is fatal in the third trimester Anti-bac acter terial ial medic medicati ations ons give give only only Anti-b temporary immunity Viruses Can only multiply in living things Reservoir is a living thing Can pass through the body filters: o Blood Brain Barrier o Placental Barrier self-limiting diseases It gives rise to self-limiting Viral infections have own time frame Example: o Col Colds las last for 2-3 2-3 days ays with ith watery secretions as symptoms After this, this, complicat complications ions would be the one present with yellowish or mucoid discharges probably indicative of sinusitis o Infl Influe uenz nza a is pres presen entt for for one one week After one week, pneumonia sets in. management for viral Medical infections: o Treated symptomatically not by anti-viral agents o Antibiotics may be used to treat secondary bacterial infections o Purp Pu rpos ose e is to incr increa ease se body body resistance
Concepts: The PA PATI TIEN ENT T is the the leas leastt sour source ce of The infection The PATIENT has the least chance to spread microorganisms o Because he manifests signs and symptoms of the disease, he is isolated o Prec Precau auti tion onar ary y meas measur ures es are are now taken The CARRIER has the highest potential to spread infection o Becaus Because e he does does not manife manifest st sign igns and symp ymptom toms of the the disease o However, he has the microorganisms 2. AGENT Microorganisms They y have have the the high highes estt popu popula lati tion on The among all living things all are susceptible to Not microorganisms microorganisms are virulent Not all microorganisms Concepts: Virulence Strength and power of microorganisms to cause infection
3. ENVIRONMENT 2
T. pallidum’s mode of transmission transmission is sexual contact o Measles’ virus mode of transmission is airborne nuclei o Salmo Salmonel nella la typhos typhosa’s a’s mode mode of transmission is fecal-oral ingestion 5. Portal of Entry A microorganism’s way in to the new host Also o corr corresp espond onds s to the indiv individ idual ual’s ’s Als body system Examples: o T. pallidum’s portal of entry is the genitourinary system o Measles’ virus portal of entry is the respiratory system o Salmonel Salmonella la typhosa’s typhosa’s portal portal of entr entry y is the the gast gastro roin inte test stin inal al tract 6. Susceptible Host Concept: Objective or goal is to limit, prevent or contr ontro ol sprea pread d of com communic nicable ble dise diseas ases es by brea breaki king ng the the chai chain n of diseases Look for the weakest link in the chain Among the six (6) factors, the MODE OF TRANSMISSION is the weakest link o It is not the CAUSATIVE AGENT because of its huge population It is not the RESERVOIR (i.e. you o cannot remove the nasopharynx in humans infected by measles virus) o It is not the PORTAL OF EXIT nor the PORTAL OF ENTRY (i.e. you canno cannott remove remove the genita genitals ls of humans infected by T. pallidum) o It is not the SUSCEPTIBLE HOST for you cannot kill it. IMPORTANT CONCEPTS!!! Typhoid mode of transmission is fecaloral ingestion First word is the PORTAL OF EXIT Second word is the PORTAL OF ENTRY DO NOT INTERCHANGE THIS!!! IMMUNITY State of having resistance State of being free from infection Two (2) Types of Immunity Natural Immunity Acquired Immunity
Must Must be condu conduciv cive e and favor favorabl able e to growth of microorganisms Example: o Clostridium tetani will not cause infe infect ctio ion n in the the pres presen ence ce of oxygen because it is an anaerobic microorganism
o
Concept: The There re must must be an inte interp rpla lay y betw betwee een n the the three factors: Host Agent Environment for infection to set in. CHAIN OF INFECTIOUS PROCESS A cycle It is continuous Six (6) Factors 1. Causative agent Microorganisms 2. Reservoir place where where micro microorg organi anism sms s can A place live and multiply Examples: o T. T. pall pallid idum um’s ’s rese reserv rvoi oirr is the the human genitalia o Measl Measles es virus virus reserv reservoir oir is the the nasopharynx o Salmonel Salmonella la typhosa typhosa’s ’s reservoi reservoirr are the Peyer’s patches of the small intestines 3. Portal of Exit From the reserv reservoir oir,, micro microorg organi anism sms s From look for a way out This pertains to the individual’s body system Examples: o T. pallidum’s portal of exit is the genitourinary genitourinary system o Measl Measles’ es’ virus virus portal portal of exit exit is the respiratory system o Salmonel Salmonella la typhosa’s typhosa’s portal portal of exit is the gastrointestinal tract 4. Mode of Transmission When outside of the host, this pertains to the the micr microo oorg rgan anis ism’ m’s s mean means s of transportation Examples: 3
1. Natural Immunity Inherent in an individual’s body tissues and fluids A person is born with it A person dies with it It is within the genes that you have these antibodies This is a rare type of immunity Example: o Race
Attenuated (weakened) microorganisms Toxoids Attenuated toxins (poisonous substances) produced by microorganisms
o
Concepts! administering vaccines or When toxoids, alcohol is NOT used to clean injection site. Use instead cotton balls with a clean bowl of water. When alcohol is used, be sure alcohol HAS DRIED OFF before administration of the vaccine or toxoid If the site has not dried off, there will be VACCINE FAILURE! Therefore, squeeze off excess alcohol
2. Acquired Immunity This is the more common type of immunity It is either a person is able to PRODUCE it or a person is able to GET it Two (2) Types of Acquired Immunity 2.1) Active Acquired Immunity actual participation of the An individual’s body tissues and fluid in PRODUCING immunity You produce the antibodies yourself when microorganisms are given to you
2.2) Passive Acquired Immunity is developed due to Immunity presence of antibodies within the serum, which is not coming from the individual itself You get it or it is given to you
Two (2) Ways of Producing Antibodies: 2.1.1) Naturally Acquired Active Immunity Antibodies are produced by nature Unintentionally Examples: o Previous attack of a disease o Chicken pox attack wherein antibodies are produced by nature Measles attack wherein o antibodies are produced by nature Sub-clinical immunity o Developed due to constant exposure to certain infection o Body produces antibodies nonintentionally by nature that provides immunity
Two (2) Types of Passive Immunity 2.2.1) Naturally Acquired Passive Immunity Done by nature given or obtained by Antibodies nature, in an unintentional manner Examples: o Infants below six (6) months seldom develop infection o Maternal transfer of antibodies o Placental transfer of antibodies o Infants who are breast-fed Colostrum intake Contains antibodies from mother given unintentionally 2.2.2) Artificially Acquired Passive Immunity of substances Administration containing antibodies in an intentional manner Examples: o Anti-toxins o Anti-serum
2.1.2) Artificially Acquired Active Immunity Body produces antibodies because it was intentionally done Examples: o Vaccines 4
Gamma globulin o Immunoglobulins IMPORTANT CONCEPTS!!! If both microorganisms and antibodies are to be given, do not give both injections on the same site Artificially Acquired Passive Immunity o Provides immediate protection o Provides immunity for only a short period as there are no reserves of it. o Immunity is lost once exhausted Active Immunity (i.e. – vaccines and toxoids) provide longer protection o Because you produced the antibodies yourself, they would be there anytime they are needed. Pregnant mother can be given tetanus toxoid Newborn receives naturally acquired passive immunity o Natural because it is from mother o Passive because it is done via placental transfer Mother receives Artificially Acquired Active Immunity Three (3) Factors to Know before taking care of Patients with Communicable Disease Know the CAUSATIVE AGENT Know what BODY SECRETION harbors the microorganism Know the MODE OF TRANSMISSION
o
Presidential Decree 996 – Compulsory Immunization for Children below Eight (8) years old Proclamation No. 6 – United Nations’ Universal Child Immunization Proclamation No.46 of 2000 – National Immunization Day
Common Goal is to prevent the seven (7) Childhood Diseases Tuberculosis (give Bacillus Calmette Guerin or BCG) Diphtheria Pertussis Tetanus Poliomyelitis (give Oral Polio Vaccine or OPV) Hepatitis B Measles (give anti-measles vaccine) IMPORTANT CONCEPT There are only two (2) PERMANENT CONTRAINDICATIONS to Immunization Allergy Encephalopathy without known cause or convulsions within seven (7) days after pertussis vaccine administration There are four (4) TEMPORARY CONTRAINDICATIONS for Immunization Pregnancy o (i.e. MMR vaccine) Recent receipt of blood products o Wait two (2) to three (3) months Very severe disease o Hospital confinement o Hospital personnel will decide when immunization would be given Immunocompromised situation
GENERAL CARE FOR PATIENTS WITH COMMUNICABLE DISEASES Two (2) Aspects Preventive Aspect Control Aspect 1. PREVENTIVE ASPECT You do not have infection yet 1.1) Health Education Main goal is to effect change in knowledge, skills and attitude Change in behavior towards health 1.2) Immunization Three (3) Laws in Immunization
5
Fever, diarrhea and colds are NOT CONTRAINDICATIONS to Immunization. Immunization can still be given despite their presence
In a private setting, the physician can POSTPONE IMMUNIZATION in the presence of fever, diarrhea, colds because patient is returned by mother to the physician once these conditions are resolved.
Current target group of Expanded Program on Immunization of the Department of Health is composed of CHILDREN BELOW FIVE (5) YEARS OLD
CDT VACCINE Cholera, Dysentery, Typhoid Vaccine Given by DOH for free Adult dose is 0.5 cc Adult injection site is the deltoid muscle Child dose is 0.25 cc Child injection site is the vastus lateralis Given INTRAMUSCULARLY (I.M.) Given when there are outbreaks of epidemic Immunity lasts only for six (6) months. Anti-Rabies Vaccine Target group would be the animals Animals are brought to the Barangay for free immunization Barangay Captain is responsible for obtaining vaccines from DOH be registered Dogs must initially before this vaccine could be administered 1.3) Environmental Sanitation Objective: No proliferation of arthropods, o rodents (both of which are good vectors) Presidential Decree 856 Sanitation Code includes submission of sex Also workers in determination of sexually transmitted diseases o For gonorrhea – two times a month o For syphilis – once a month o Physical Examination – once a month
2. CONTROL ASPECT Done when signs and symptoms are already present There is already the presence of infection Goal is to limit the infection
2.1) Isolation Separation of an infected person during period of communicability Two (2) ways of Isolation 2.1.1) Strict Isolation Intended to protect other persons (not the patient) from infection It intends to limit the microorganisms to be within the patient 2.1.2) Reverse Isolation Also called Protective Isolation to protect the Intended immunocompromised patient from infection Intends to keep microorganisms out of the patient Concepts: Quarantine Limitation of freedom of movement of a well person during the longest incubation period It involves the separation of persons who are carriers These are persons who are not sick These are persons who do not manifest signs and symptoms of the disease
Presidential Decree 825 Anti-Littering Law Proper disposal of garbage Anyone caught littering would have a penalty of Php2,000 to Php5,000 and imprisonment for one (1) year. 1.4)
Proper Supervision Handlers
of
A responsibility of the Department of Health facilitated by its Sanitary Inspectors Also a responsibility of the Bureau of Food and Drug Monitors food and drug sold to public to assure that it is safe for consumption
Center for Disease Control’s two (2) Revised Isolation Precautions 1) Standard Precaution Best strategy to prevent nosocomial infection taking place of Universal Slowly Precaution
Food
6
3. Avoidance of Needle Stick or Sharps Injury Do not recap, bend or break needles must be puncture-resistant There sharps collector
Applies to all patients regardless of their diagnosis Applies to blood and all body fluids, excretions and secretions except sweat. Applies to mucous membrane and non-intact skin Concept: Universal Precaution Has double standards Used only if patient is diagnosed or suspected of having blood-borne diseases Elements included in Standard Precautions 1. Practice hand washing for each patient care For contact with body fluids of patient Duration is 10 – 15 seconds Length of washing is not important What is important is the friction that is applied Concepts: For Medical Asepsis: Hand is lower than the elbow Hand is the dirtiest part Elbow is the cleaner part
IMPORTANT CONCEPT!!! If patient is diagnosed as having communicable disease, practice both Standard Precaution and Transmission-based Precaution Transmission Based Precaution Airborne Precaution Use of mask Special ultrafilterable mask Particulate mask o For measles, chicken pox, TB Droplet Precaution No contact to mucous membrane, nose, mouth Use mask – ordinary mask will do Use goggles o For meningitis, mumps, pertussis, German measles, diphtheria Contact Precaution Avoid person to person contact Use gloves Use gown diarrheal diseases, typhoid, For cholera, hepatitis, skin diseases like ringworm, scabies and pediculosis
For Surgical Asepsis: Hand is placed up and remains up Hand is the cleanest portion Elbow is less clean than the hands 2. Use of Protective Barriers or Use of Personal Protective Equipment (PPEs) If you wear them all, the correct sequence for wearing them would be: o Mask o Goggles o Cap / Bonnet o Gown o Gloves If you are about to remove them, the correct sequence is: o Gloves o Do hand washing o Gown o Cap / Bonnet o Goggles o Mask
Control Measures other than Isolation 1. Disinfection Killing of pathogenic microorganisms by physical or chemical means (i.e. boiling, soaking) Types of Disinfection Concurrent Disinfection Done when the person is still a source of infection Example: o When patient is still in the hospital Boil all patient gowns
7
Terminal Disinfection Done when person is no longer a source of infection Example: o Room of patient is cleaned upon discharge of patient using UV rays or Lysol
o
Important Concepts: When inside the human being, the spore transforms into a VEGETATIVE FORM, which can be destroyed by the presence of oxygen Why is Clostridium tetani abundant in soil? o Normal habitat of C. tetani is in the intestines of herbivorous animals (i.e. cows, carabaos, goats, sheep, horses) o Manure of these animals is used as fertilizer Mode of Transmission of C. tetani o Break in skin integrity Person is at risk for infection when there is any kind of would (i.e. splinter or salubsob, tooth decay, otitis media)
2. Disinfestation Killing of undesirable small animal forms such as arthropods, rodents, insects by physical or chemical means 3. Fumigation of gaseous agents to Use arthropods, rodents and insects.
kill
4. Medical Asepsis Hand washing Gloving Gowning Masking Placarding o Placing “NO SMOKING” sign when there is oxygen inhalation in progress.
COMMUNICABLE DISEASES CENTRAL NERVOUS SYSTEM
OF
Bacterial infections Tetanus Meningitis Viral Infections Encephalitis Poliomyelitis Rabies TETANUS Also called LOCKJAW With painful muscular spasms Ten times more painful than cramps
Sterilization is needed to kill the microorganism
Important Concepts! You need not be wounded by a RUSTY OBJECT to acquire tetanus In the newborn, tetanus neonatorum is caused by poor cord care. When C. tetani enters the body, it seldom migrates to the bloodstream where oxygen is present C. tetani remains in the wound but the effects are systemic
THE
IMPORTANT CONCEPT! Toxin is released to the blood and is responsible for the manifesting signs and symptoms of the disease Two (2) Types of Toxins in Tetanus 1. Tetanolysin Dissolves red blood cells Results to anemia Thus, patient is pale-looking
leg
Clostridium tetani o Causative agent of Tetanus o Anaerobic microorganism o Abundant in soil, dust, clothing o It exists in the form of a SPORE outside the human body o That is why it survives outside the human body even in the presence of oxygen
2. Tetanospasmin Causes muscle spasm Acts on MYONEURAL JUNCTION of the muscles and on the INTERNUNCIAL FIBERS of the spinal cord and the brain. Results into multiple muscle spasms 8
Inhibits the spastic muscle from sending transmissions to the brain, which would inhibit progression of spasms. Due to this, adjacent muscles will also undergo spasm similar to a chain reaction or a domino reaction.
In the wound, there would be inflammatory response: Rubor - rednes Calor - heat Tumor - swelling Dolor - pain Functiolaesa – loss of function
Resulting into constipation Abdominal muscles are affected o Results into abdominal rigidity o Abdomen is hard as a board o This sign serves as a basis for recovery o If abdominal rigidity decreases, it means that the patient is on his way to recovery Extremity muscles are affected o Results into stiffness of extremities o There is difficulty in flexing o Robot gait is evident o
an
Signs and Symptoms of Tetanus The patient manifests: o Restlessness o Fever o Profuse Sweating IMPORTANT CONCEPTS!!! Masseter muscle is involved o It functions for mastication, for opening and closing of the mouth o Tetanus affects strong muscles Therefore, it affects the closing o of the mouth muscle o This is called LOCKJAW or TRISMUS Facial muscle is affected Gives rise to “risus sardonicus” o o Known as the “Sardonic Smile” o Also known as “Ngiting Aso” o Patient is smiling but his eyebrows are raised. Spinal muscle is affected o Resulting into the Ophistotonus position o This is the arching of the back In the vernacular, it is called o “LIAD” Respiratory muscles are affected o Results to difficulty of breathing, dyspnea and chest heaviness tract muscles are Genitourinary affected o Results into urinary retention o Intervention would involve catheterization Gastrointestinal muscles are affected
Concept! Thus, almost all of the muscles are rigid and stiff in Tetanus! Diagnostics for Tetanus: 1. Clinical Observation Assess patient physically Assess for the presence of lockjaw If this is positive, a logical question would be – “Do you have a wound” 2. Obtain history of wound Wound Culture there is a fresh wound, If microorganism is still present there Concept: The shorter the incubation period, the poorer the prognosis Shortest incubation period is 2 – 3 days. An incubation period of one month has a better prognosis than an incubation period of 2 – 3 days. Three (3) Objectives Management
of
Medical
Neutralize the toxin This is the top priority The toxin is responsible for the signs and symptoms of the disease and the systemic infection Give anti-tetanus serum or tetanus anti-toxin o It comes from a horse serum o Do skin testing first 9
o
If (+) for skin testing, DO NOT GIVE the drug. Resort to human serum – tetanus immunoglobulin
o
Concept: In the Philippine setting, the horse serum is still given despite a positive skin test. This is done by giving fractional doses. Example: o Initial administration of 0.01 of drug and 0.99 PNSS o After 30 minutes, 0.05 of the drug and 0.95 of PNSS o After another 30 minutes, another increase in the dose of the drug
The more frequent the spasm, the faster the rate of the titration
When the patient is on his way to recovery, muscle relaxants per orem may be used: o Methocarbamol or Robaxin o Lionesal or Baclofen o Eperison or Myonal
Proceed with other supportive management urinary retention, do For catheterization For constipation, administer laxatives as ordered Nursing Management in tetanus Muscle spasms are the first concern Concept: Stimuli trigger spasms. Types of Stimuli:
IMPORTANT CONCEPT!!! When administering tetanus horse serum, always have ready the following: o EPINEPHRINE o CORTICOSTEROID These would be necessary to counteract any delayed reaction, which may cause hypersensitivity reactions leading to anaphylaxis and eventually the death of the patient. 2. Kill the Microorganism Give Penicillin o This is the drug of choice to kill the bacteria In the fresh wound, do daily cleansing with the use of hydrogen peroxide Then apply antiseptic solution like Betadine or Povidone Then cover wound with THIN DRESSING to allow air to circulate through the wound. It may also be good to expose the wound but avoid contact with flies.
1. Exteroceptive Comes from outside environment of the patient Examples are bright light and noise Place the patient in dim and quiet environment 2. Interoceptive Comes from inside or within the patient Examples are stress, pain, coughing, passage of flatus 3. Proprioceptive There is participation of patient and other persons are touching, turning, Examples jarring the bed of the patient Nursing Care in Tetanus Done to prevent patient from having spasms Place the patient in a dim and quiet environment minimal handling of the Practice patient o Avoid unnecessary disturbance of the patient Practice Cluster Care o Do all nursing care activities in one setting o Do other nursing care activities with vital signs taking
3. Prevent and Control Spasm Give muscle relaxant o Given during the acute phase of tetanus o Done via the I.V. route Give Diazepam / Valium o Use I.V. push or I.V. drip Concepts: I.V. drip regulation is titrated based on the frequency of the spasm. 10
Diphtheria Pertussis Tetanus Vaccine or DPT vaccine When given: o 1st Dose: 6 weeks after birth; 0.5 ml o 2nd Dose: 10 weeks after birth; 0.5 ml o 3rd Dose: 14 weeks after birth; 0.5 ml Number of Doses: o Three (3) Interval between Doses: o Four (4) weeks Administration Site: o Vastus lateralis muscle Route: o Intramuscular
Gentle handling of the patient Touching is not contraindicated Turning is not contraindicated o However, do these as gently as possible o Inform the patient before proceeding with any procedure Concept: o Tetanus patients are isolated so as not to be exposed to stimuli
Prevent injury: Respiratory injury Airway obstruction Tongue could be drawn back and cause blockage or obstruction Use padded tongue depressor for retaining patency of the airway Respiratory Infection Turning to side is usually not done o This results to pooling of respiratory secretions in the lungs o This leads to pulmonary infection Profuse sweating and draft exposure also leads to pulmonary infection Therefore, always keep patient dry; especially at the back.
IMPORTANT CONCEPTS!!! fever to set in after Expect administration of DPT vaccine o Give paracetamol o Apply warm compress for better drug absorption o Immediately follow up with cold compress to avoid soreness If tenderness or swelling on site of injection is present: o Do cold compress within twenty-four (24) hours o Then do warm compress Observe for signs of convulsions within seven (7) days after DPT immunization This indicates that child has o reaction with the pertussis component of the drug o Therefore, succeeding doses of DPT will NOT BE GIVEN o Give ONLY the DT components o If DPT is given again, this predisposes the child to neurologic disorders Observe if child cries uncontrollably This is an indication of development of neurologic disorders.
Physical Injury For falls: o Never leave the patient alone o If you do leave the patient, keep the padded side rails up o Keep call light within the reach of the patient Fractures due to spasm: o Caused by restraining by relatives Provide Patient with Comfort Measures Oral care o To prevent mouth sores o Cotton swab used on inner and outer chick o Do not use toothbrush IMPORTANT CONCEPT!!! of tetanus does Attack permanent immunity
not
DPT Immunization for Individuals Dose: 0.5 ml Route: Intramuscular Number of Doses given:
give
Vaccine Given: 11
Pregnant
Key Concept!!! Avoid Wounds
Two (2) doses with three (3) booster doses or; o Two (2) doses with booster dose given every pregnancy When given: o 1st Dose: Anytime during second trimester of pregnancy o 2nd Dose: With one (1) month interval o Booster Dose: Given with successive pregnancy/ies o
MENINGITIS of the meninges Inflammation (covering of the brain and spinal cord) Concepts! Meninges are composed of: o Dura mater o Arachnoid mater o Pia mater Cerebrospinal Fluid or CSF is found in the SUBARACHNOID SPACE
For High-Risk Individual 1st Dose given: 03-05-2005 o 2nd Dose given: o 04-05-2005 3rd Dose given: o 10-05-2005 (six months after the LAST dose) th 4 Dose given: o 10-05-2006 (After one (1) year from the LAST dose) th 5 Dose given: o 10-05-2007 (After one (1) year from the LAST dose)
Causative Agents in Meningitis Viral o CMV – Cytomegalovirus Opportunistic infection for AIDS Fungal o Cryptococcal Meningitis Source is excreta of fowls and feathered animals Another form of opportunistic infection for AIDS Bacterial o Tubercle Bacilli TB meningitis Staphylococcal meningitis o Secondary to skin infection Haemophilus influenzae bacilli Common cause of meningitis in o the United States Meningococcemia o Meningococcemial meningitis o Spotted Fever Disease o Most fatal o The only type of meningitis where the VASCULAR SYSTEM is affected o Bleeding is triggered o Disseminated Intravascular Coagulation occurs and leads to vascular collapse o Vascular collapse leads to death in ten percent (10%) of patients o This ten percent (10%) has the FULMINANT TYPE or the Waterhouse-Freiderichen Syndrome (characterized by vascular collapse)
IMPORTANT CONCEPTS!!! Succeeding doses of Tetanus Toxoid are given based on DATE OF LAST DOSE If a person is high-risk, give booster dose every five (5) years If a person is low risk, give booster dose every ten (10) years of Tetanus Toxoid Effect administration on the Mother Slight soreness or heaviness on site of injection Wound Care Wash wound with soap and running water Place antiseptic solution on wound Use thin dressing Band Aid Plastic Strips are allowable as they have air ventilation holes Do not use plaster Use only those types of plasters with air ventilation holes to introduce oxygen to the wound 12
o
Causative agent meningitides
is
Neisseria
Important Concept! In children below four (4) years old, Neisseria meningitidis is a normal flora in the nasopharynx. If resistance goes down, these children become prone to infection Mode of Transmission Droplet transmission In cryptococcal meningitis: o Inhalation of spores Portal of Entry system via the Respiratory nasopharynx Pathophysiology of Meningitis the nasopharynx, the From microorganism goes to the bloodstream in the bloodstream, the Once microorganism causes petechiae formation (pin point red spots on the skin) From the bloodstream, microorganism goes to the meninges and irritates them o There is inflammation of the meninges and accumulation of substances in the meninges This results into increased Intracranial Pressure (ICP) o Increased ICP leads to: Severe headache Projectile Vomiting Two (2) to three (3) feet away from patient o Management involves turning patient to side Position kidney basin about two (2) to three (3) feet away Altered Vital Signs o Increased Temperature o Decreased Pulse Rate o Decreased Respiratory Rate o Increase in Systolic Blood Pressure and Normal Diastolic Pressure This results in the widening of the Pulse Pressure Convulsions (seizures)
Diplopia o Due to choking of optic discs o Double vision but not crossed eyed o Determined by finger counting Altered level of consciousness
Pathophysiology of Meningococcemia of entry of Neisseria Portal meningitidis is also the nasopharynx The bacteria then goes to the bloodstream Presence of bacteria in the bloodstream causes ecchymosis o These ecchymoses are blotchy (pantal-pantal) purpuric lesions o They are purplish in color Usually found on the wrist and o the ankles From the bloodstream, they go to the meninges and irritate them. Same sequence of events follow as mentioned above Signs and Symptoms of Meningitis Once the microorganism is at the nasopharynx: o Fever o Headache o Sore throat o Cough o Colds Other signs and symptoms present as discussed in the pathophysiology Pathognomonic Sign of Meningitis Nuchal Rigidity Stiffening of the neck o No flexing of the neck o No hyperextending of the neck o No turning from side to side Abnormal Reflexes o Positive for Kernig’s Sign Place patient in supine position Flex both knees toward the abdomen Then ask the patient to extend the legs If pain is present, the patient is said to be positive (+) for Kernig’s 13
Sign or difficulty of extending the leg Positive for Brudzinski’s Sign o Place the patient in supine position o Flex the neck If there is no reaction, the o patient is said to be negative (-) for Brudzinski’s Sign. o If there is INVOLUNTARY DRAWING UP of the LEGS / HIP upon flexion of the neck, the patient is said to be positive (+) for Brudzinski’s Sign
This will bring about HERNIATION OF THE BRAIN and would eventually lead to death Therefore, it is important that the nurse performs Physical Assessment before doing a lumbar tap. 2. Blood Culture Done because microorganism can travel to the bloodstream Medical Management of Meningitis If bacterial o Give anti-bacterial agent in the form of antibiotics If viral o Symptomatic If fungal o Give Amphotericin B If with inflammation Give corticosteroids in the form o of DEXAMETHASONE o Never give PREDNISONE Prednisone does not cross the Blood-Brain barrier Prednisone causes sodium retention Retains CSF If with excess CSF o Give osmotic diuretic in the form of MANNITOL o Check blood pressure before administration as it causes hypotension o Monitor the intake and output to evaluate the effectiveness of Mannitol o Expect that after two (2) to three (3) hours, the urine output must increase by thirty (30) to fifty (50) ml. o If no changes in urine output occurs, then Mannitol is not effective o Refer this to the physician If there are convulsions due to CNS infection o Give anti-convulsants Dilantin Phenytoin Routes of Administration of Dilantin o Per Intravenous o
Diagnostic Tests for Meningitis 1. Lumbar Puncture Fluid (CSF) is the Cerebrospinal specimen used Assess for the color of the CSF o Bacterial infection is present if: o CSF is yellowish, turbid, cloudy Viral infection is present if: o CSF is clear No infection is present if: o CSF is clear Send CSF for Laboratory Examination Laboratory findings would show: o Increased protein levels o Increased White Blood Cell levels o Decreased Sugar content Concepts If caused by bacteria, do Culture and Sensitivity test o This is done to know what bacteria caused the infection o This is also done to determine what drug will be used to kill the offending microorganism If CSF is clear, it is subjected to Counter Immuno-Electrophoresis (CIE) This is done to determine if causative agent or a protozoa IMPORTANT CONCEPT!!! In patients with HIGHLY INCREASED INTRACRANIAL PRESSURE due to CNS infection, lumbar puncture or aspiration of the CSF is CONTRAINDICATED
14
Nursing Care for I.V. administration of Dilantin Sandwich Dilantin with NSS NSS – Dilantin – NSS Rationale: Dilantin would crystallize Per Orem Nursing Care for P.O. administration of Dilantin Do frequent oral care Do gum massage Rationale: Dilantin causes gingival hyperplasia or overgrowth of the gums
Place call switch and light within reach of patient 4. Potential for fluid and electrolyte imbalance due to projectile vomiting Monitor intake and output Provide fluids per orem Important Concept An attack of meningitis does not provide permanent immunity
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Preventive Measures 1.Proper disposal of nasopharyngeal secretions Burning Burying procedure for disposal of Proper nasopharyngeal secretions o Use tissue paper o Put it in a plastic bag after use o Knot the plastic bag o Dispose plastic bag in a trashcan Important Concepts! The best and most economic way preventing spread of infection is through swallowing of nasopharyngeal secretions o This brings the secretions to the stomach and to the intestines and would then be eliminated in the stool have less chance of Children spreading infection because they swallow nasopharyngeal secretions. This is contraindicated, however, for tuberculosis patients Thus, for TB patients, they have to spit out nasopharygeal secretions for other Swallowing is allowable respiratory infections
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Important Concept! Dilantin is never given Intramuscularly o This is irritating to the tissues o This has an erratic effect Nursing Care Symptomatic Supportive Nursing Diagnoses 1. Alteration in body temperature related to infection Priority is to lower body temperature o Do TSB o Provide cold compress o Provide loose clothing 2. Pain: Alteration in comfort related to increased Intracranial Pressure Priority is to relieve headache within thirty (30) minutes o Provide diversion o Provide proper positioning Low-Fowler’s position (30° incline) o Provide comfort measures Massage the forehead o o Do petrissage with circular action 3. Potential for injury related to altered level of consciousness Never leave the patient alone
2. Cover nose and mouth when sneezing and coughing Important Concepts! When you transfer patient… o Make the patient wear a mask so as not to infect people in the hallway, elevator, etc. when you enter the Wear mask patient’s room 15
3. Vaccine Hib vaccine for Haemophilus influenza
temporary immunity, due to causation by various viruses
BRAIN FEVER Arbovirus Arthropod-borne Virus Primary cause St. Louise Japan B Australian X: Equine (E-W) Mode of Transmission Mosquito bites o Aedes Sollicitans Culex tarsalis o Ticks of horse Migratory birds Secondary cause Post racene encephalitis Toxic Metal poisoning o Lead poisoning o Mercury poisoning
Source of infection is mosquito
Preventive Management: CLEAN PROGRAM o C – Chemically Treated Mosquito Net o L – Lavivorous fishes o E – Environmental Sanitation o A – Anti-mosquito Soap (Basic Soap) o N – Neem Trees or Eucalyptus Tree (draws away mosquitoes) Concepts! To kill mosquitoes in canal, pour oil or gas in canal o This depletes oxygen present in the canal o There is no need to light it up POLIOMYELITIS Also called: o Infantile Paralysis o Heine-Medin Disease Affects children below ten (10) years of age Less risk for people above ten (10) years Old
ENCEPHALITIS Signs and Symptoms With altered level of consciousness With lethargy o Difficult to awaken o Patient is abnormally sleepy With behavioral changes Brain is immediately affected relative to meningitis
Causative Agent Virus o Legio debilitans Type 1 – Brunhilde Type 2 – Lansing Type 3 – Leon If Brunhilde o Gives permanent immunity If Lansing or Leon o Gives temporary immunity
Diagnostic Tests 1. Lumbar Puncture Specimen is cerebrospinal fluid (CSF) Laboratory Results would indicate: o Increased Proteins o Increased White Blood Cells o Normal Sugar Content
Important Concepts! When Brunhilde infects you, Leon or Lansing will no longer affect you!
2. Electroencephalogram (EEG) To assess extent of brain damage Patient recovers but because he is epileptic, he develops irreversible brain damage Medical Management Symptomatic due to viral cause Concepts! No permanent immunity is obtained from attack of encephalitis, only
In the Philippines, the most prominent type is Brunhilde! Mode of Transmission Droplet o In early stage of infection, virus if found at nasopharyngeal secretions
16
Fecal-Oral Route o In late stage of transmission, virus is found at the mouth
Do not do massage No positioning will relieve patient Instead, what would relieve the patient would be: Application of warm packs Analgesics Never administer Morphine It is a narcotic analgesic that would cause respiratory depression
o
Portal of Entry Gastrointestinal Tract Pathophysiology debilitans goes to the Legio nasopharynx or the mouth If in the nasopharynx, it goes to the tonsils and causes: o Sore throat o Fever and chills o Headache with body malaise If at the mouth, it goes to the Peyer’s patches and causes: o Abdominal pain Anorexia o o Nausea and Vomiting o Diarrhea or Constipation
o
Once in the CNS, the microorganism will also cause: o Stiffness of the hamstring o Patient will be positive for HOYNE’S Sign and exhibit a HEAD DROP o To check for Hoyne’s Sign Lift shoulders of patient when lying supine or extend head of patient beyond the edge of the bed If head of patient drops, he is said to be positive (+) for Hoyne’s Sign
Once in the microorganism is in the CNS, the patient would elicit a POKER SPINE o Ophistotonus with head retraction o Sitting position cannot be assumed o Therefore, patient will assume a TRIPOD POSITION
STAGES of POLIOMYELITIS 1ST Stage: Invasive Stage or Abortive Stage All the abovementioned signs and symptoms will appear Patient recovers Disease process is aborted But there will be instances when disease process will not be aborted Tonsils Peyer’s Patches ▼ ▼ Cervical Mesenteric Lymph Lymph Nodes Nodes ▼▼▼ ▼▼▼ BLOODSTREAM ▼▼▼ Central Nervous System
Central Nervous System ▼▼▼ Paralysis Concept! the CNS, the patient will From experience paralysis. This leads to the third (3rd) stage of the disease rd 3 Stage: Paralytic Stage Presence of paralysis Characteristics of Paralysis: o Flaccid Soft Flabby
2nd Stage: Pre-paralytic Stage of Poliomyelitis Central Nervous System is already involved but there will be no paralysis Signs and Symptoms: Once in the CNS, microorganism will cause: o Sever muscle pain Do not keep on turning or holding patient 17
Limp Important Concept! Flaccid Paralysis is PATHOGNOMONIC SIGN of Poliomyelitis
About ten (10) days after being affected 5. Nasopharyngeal Examination Performed at the early stage Medical Management Symptomatic Causative agent is viral If there is respiratory paralysis patient in a MECHANICAL Place VENTILATOR Use the IRON LUNG MACHING o This works on the principle of Negative Pressure Breathing o No tracheostomy tube needed (tracheostomy tube or endotracheal tube work on the principle of Positive Pressure Breathing) o Capsular in shape o With glass windows o With metal plate o Works on electricity o During brownout or power shortages, operate the machine manually o It has a steering wheel, which can be manipulated manually o Patient stays in the Iron Lung Machine for months Nursing Care for Poliomyelitis Symptomatic and Supportive Psychological Aspect of Care o Use empathy
Three (3) Types of Paralysis 1. Bulbar Type Cranial nerves are affected 9 Th cranial nerve (Glossopharyngeal Nerve) and 10 th cranial nerve (Vagus Nerve) affectations give rise to: o Respiratory problems o Vocal cord swelling / paralysis o Excessive salivation o Aspiration o Regurgitation 2. Spinal Type Most common type of paralysis Affects ANTERIOR HORN CELLS Affects MOTOR FUNCTION o Paralysis of extremities o Paralysis of intercostal muscles leads to DIFFICULTY OF BREATHING 3. Bulbo-Spinal Type Combination of Bulbar and Spinal types Patient has cranial nerve affectations and anterior horn cell affectations Important Concepts!!! Not all patients will develop paralysis If patient is non-paralytic, o He has GOOD PROGNOSIS Diagnostic Tests
Preventive Measures 1. Immunization Vaccine given: o Oral Polio Vaccine (OPV) or Sabin o Dose: Two (2) to three (3) drops o Route: Oral o Number of Doses: Three (3) o Interval: Four (4) weeks o When given: 1st Dose – at six (6) weeks old 2nd Dose – at ten (10) weeks old
1. Lumbar Puncture Laboratory results would reveal: o Increased White Blood Cell levels Increased Protein levels o o Normal Sugar levels 2. Muscle Testing To determine what specific muscle is affected 3. Electromyelogram To determine extent of muscle involvement 4. Stool Examination Perfomed at the late stage 18
2. Avoid mode of transmission Proper disposal of nasopharyngeal secretions Cover mouth when coughing Do not put anything through the mouth
3rd Dose – at fourteen (14) weeks old Important Concepts!!! Do not feed child for thirty (30) minutes after administration of OPV Rationale: For better absorption If child vomits, REPEAT!!! If child has diarrhea Give OPV But do not record it Not all of the vaccine may be absorbed properly When OPV 3 is given four weeks after, record it as OPV 2
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RABIES Also called: o Hydrophobia o Lyssa o La Rage A disease of a low form of animal o Not a human infection o Only accidentally transmitted to man Occurs in canine animals or animals with fangs: o Fox o Wolves o Boar o Monkeys o Bats o Cats o Dogs
Integrated Management of Childhood Illnesses (IMCI) o Tell mother also that she should be very careful in handling stool of child because this vaccine eliminates virus to the stool o If significant others at home are immunocompromised o Do not administer OPV o Due to feces of child o Rather give, IPV or Inactivated Polio Vaccine / SALK o Dose: 0.5 cc o Route: Intramuscular o Number of Doses: Three (3) o Interval: Four (4) weeks o When given: 1st Dose – at six (6) weeks old 2nd Dose – at ten (10) weeks old 3rd Dose – at fourteen (14) weeks old o Rationale: Because stool of child may contain the virus if OPV is given
Causative Agent: Rhabdovirus o A neurotropic virus o Has special affinity to neurons and the Central Nervous System R H A B D O V I R U S ▼▼▼ ▼▼▼ Peripheral Efferent Nerves Nerves ▼▼▼ ▼▼▼ CNS Salivary Pathologic Gland Lesions of Rabid (negri bodies) Animal
Important Concept! Pathologic lesions that are formed as microorganism multiplies If there is no multiplication of the microorganisms at the Central Nervous System, there will be NO negri bodies. Mode of Transmission Contact with saliva of a rabid animal 19
Stage 1 – Invasive Stage Numbness on the site of the bite Itchiness on the site of the bite Flu-like symptoms Fever o o Headache o Sore throat Marked Insomnia Restless Irritable Apprehensive Slight photosensitivity Vague symptoms
Important Concept! Therefore, you need not be bitten Even a scratch could cause rabies as animals lick their paws Infection may occur through: o Corneal transplantation o Kissing animal o Dog licking wounds Manifestation: In Animals o Incubation Period Three (3) to eight (8) weeks
Important Concept! When a family member at home is bitten by a rabid animal, vaccinate all people at home because patient has virus at saliva
Stages of Manifestations in Animals Stage 1 – Dumb Stage Animal will have complete change in disposition May show any of the following behaviors: o Withdrawn o Stays in one corner o Depressed o May be overly affectionate Can lick wounds o May be walking to and from o Hyperactive o Manic It is better if the animal is withdrawn as it is easy to note
Stage 2 – Excitement Stage Acrophobia o Fear of Air Hydrophobia o Fear of Water Important Concept! and Water both cause Air PHARYNGOLARYNGEAL SPASM This is characterized by: o A drowning sensation o Strangulation to death syndrome o Like breathing in thick smoke Other signs and symptoms o Photosensitivity o Maniacal behavior o Resembles attitude of a rabid animal o Easily agitated o Runs after people o Violent Club walls o o Jumps out of window Important Concepts! Before, THORAZINE and BENADRYL were given for maniacal behavior but had proven to be ineffective Now, HALOPERIDOL and BENADRYL are administered and are very effective against maniacal behavior Stage 3 – Paralytic Sage Patient’s spasms will stop
Stage 2 – Furious Stage Easily agitated Easily bites With vicious look With drooling of the saliva Expect the animal to die Dying and biting happens on this stage Animal can die without biting Manifestation: In Humans o Incubation Period Ten (10) days to twenty one (21) years (this is the longest incubation period recorded in the Philippines) 20
He can be fed, etc., Paralysis sets in from toes going upwards If respiratory system is affected, the patient will die Manifestation of signs and symptoms sets within 24 hours and death follows Important Concept!!! Rabies is a preventable but not a curable disease Maximum time before death occurs is seventy-two (72) hours.
Submit yourself for treatment at once if: You have multiple bites You have a deep bite o Reason for the Bite If bite is provoked Example: You stepped on the dog’s tail Do not worry If unprovoked Example: There is no reason Then, WORRY, because IT IS A RABID DOG!!! Medical Management Post-Exposure Prophylaxis Vaccines
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Diagnostic Tests Done Before Patient Manifests Signs and Symptoms
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Important Concept! There is no diagnostic examination done to humans, ONLY TO ANIMALS Brain Biopsy of the Animal Identifies presence of negri bodies 10% of animals have rabies but are negative for negri bodies o Because virus may travel through efferent nerves and may not have reached the CNS before death Therefore, do the next test…
Active Form of Vaccine Made up of microorganisms Purified Vero Cell Vaccine o PVCV o One of the more common types o Verorab o Stock dose is 0.5 cc / vial
Direct Fluorescent Antibody Test (DFA Test) Confirmatory test for rabies Observation of the Animal Done for ten (10) days Important Concept! o Submit yourself for treatment if, within ten (10) days: Animal dies Animal shows behavioral changes Consider the following: o Site of Bite If above waist Submit yourself for treatment as soon as possible This is due to the proximity of the bite to the brain o Velocity of Virus millimeters per Three hour (3mm/hr) Extent of Bite o
Purified Duck Embryo Virus o PDEV o Lyssavac o Stock dose is 1.0 cc / vial
Purified Chick Embryo Cell o PCEC o Also one of the more common types o Rabipur o Stock dose is 1.0 cc / vial
Important Concepts!!! If given intramuscularly (I.M.) o Do skin testing first If given intradermally (I.D.) o No skin testing is done Site Deltoid o o Vastus lateralis Important Concepts!!! If active form of vaccine If via I.M.
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Schedule is: Dose Day Exam ple st 1 00 03/05/ 2005
Dosa ge 2 vials
2nd
07
3/12/ 2005
1 vial
3rd
21
3/26/ 2005
1 vial
Rema rks 1 cc on each site; One on the left and one on the right One site only One site only
Important Concepts!!! Concepts!!! Counti ting ng is AL ALWA WAYS YS BASE BASED D on the the Coun FIRST DOSE!!! You can afford not to continue vaccine if dog does not die after ten (10) days However, continua continuance nce is encourag encouraged ed However, because doing so would give three (3) years of immunity If you abort vaccination, you will not get three (3) years of immunity When you get bitten again, you start all over again In case the dog: o Died o Disappeared o Was killed within (3) days of complete doses plus a Avail BOOSTER DOSE Booster Dose o Given at DAY 91 In the tabulated example Schedule would be at 6/05/2005 Dosage is one vial If via I.D. Schedule is: Dos Da Exam Dosag Remar e y ple e ks st 1 00 03/05/ 0.1 cc Given 2005 if on Verora each b site: or Right •
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2nd
03
3/08/ 2005
3rd
07
3/12/ 2005
4th
28 to 30
04/01/ 2005 to 04/03/ 2005
5th
90
06/03/ 2005
0.2 cc if Lyssav ac Or Rabipu r 0.1 cc if Verora b or 0.2 cc if Lyssav ac Or Rabipu r 0.1 cc if Verora b or 0.2 cc if Lyssav ac Or Rabipu r 0.1 cc if Verora b or 0.2 cc if Lyssav ac Or Rabipu r 0.1 cc if Verora b or 0.2 cc if Lyssav ac Or Rabipu
and Left
Given on each site: Right and Left
Given on each site: Right and Left
Given on one site only
Given on one site only
r Important Concepts!!! Concepts!!! Verorab o Once reconstituted is only potent for eight (8) hours Anti tibo bodi dies es are are prod produc uced ed in abou aboutt An seven (7) days Therefor fore, e, also also give give passiv passive e form form of There vaccine. Passive Forms Temporary antibodies
Half is given Intramuscular On the ventrogluteal muscle or at the side of the buttocks Other half is... Infiltra Infiltrated ted around around site of bite bite usin using g four four dist distin inct ct points or Given inside the wound of the patient This is prophylactic and is not considered as a treatment
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Animal Serum Equine Rabies Immunoglobulin (ERIG) o Anti-rabies serum o HyperRab o FaviRab Important Concepts! Do skin test first o If nega negati tive ve for for skin skin test test,, give give drug Dosage is based on body weight and is provided in direct proportion 0.2 cc / kg body weight is the standard Example: A 50 kg person woul would d rece receiv ive e 10 ml of ERIG Cost is approximately Php1,800 / 5.0 cc o If posi positi tive ve for for skin skin test test,, give give HRIG or Human Rabies Immunolobulin Imogam Rabuman 0.133 cc / kg body weight is the standard dose Example: A 50 kg person would receive 6.65 cc of HRIG Cos Cost is appr pproxim ximately tely Php4,500 / 2.0 cc o This is given as a single dose within seven (7) days from the date of the bite After seven days, patient o already has antibodies o Computed Dosage is divided in two
Nursing Care Place pati patien entt in a dim and quiet uiet Pla environment Keep pati patien entt away away from from subsub-ut util ilit ity y Keep room Restrain the patient before he exhibits maniacal behavior all Personal Protective Wear Equipment when you enter the room because patient continues to spit Preventive Measures Be a responsible pet owner o Have pets immunized Wash woun wound d with with soap soap,, wate waterr and and Wash antiseptic Then observe the dog Important Concept!!! Virus rabies is destroyed by 60°C heat for thirty-five (35) seconds Therefore, you will not acquire rabies from eating dog meat
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COM COMMUNICA ICABLE DISEA ISEAS SES OF THE CIRCULATORY SYSTEM DENGUE HEMORRHAGIC FEVER Important Concept! Fever is different from Dengue Dengue Hemorrhagic Fever! Dengue fever is an affectation of the circulatory system without bleeding o It is a mild form of hemorrhagic fever Causative Agent: Arbovirus Carried from one person to another by an Arthropod Types of Dengue Viruses Type 1 – Onyong-nyong virus
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Type 2 – Chikungunya Type 3 – West Nile Type 4 – Flavivirus o Brou Brough ghtt epid epidem emic ics s in seve severa rall areas in the Philippines Mode of Transmission Mosquito Bite Biological Transmitters Transmitters o Aedes aegypti o Aedes albopectus Transmitter Mechanical Transmitter o Culex fatigans Biological Transmitter Afterr this this mosq mosqui uito to has has bitt bitten en an Afte infected person, after eight (8) to ten (10) days, it can transfer virus to other people Virus becomes a part of the system of the mosquito as long as it is alive Life span of these types of mosquitoes is four (4) months Mechanical Transmitter mosquito bites an infected infected After this mosquito person, the very next person it bites is the only person who gets the virus. One is to one Immediate transfer of virus Aedes aegypti More common in the Philippines Day-biting Low-flying Low-extremity biting eeds on clear ear, stagn tagna ant water ater Breeds usually in urban area o Old tires o Flower vases o Plant cans In the Philippines, any area is a dengue risk area information: Other information: o When it lan lands on a surfa urfac ce, body of mosquito is on a PARALLEL POSITION and two (2) legs are raised o It has white stripes on legs o It has a gray-millennium gray-millennium color
Four Classifications Hemorrhagic Fever
of
Incr Increa ease sed d grad grade e feve feverr (las (lasts ts 3 – 5 days) o Even Even if antipy antipyret retics ics are given, given, fever will persist o Fever Fever will will come come down down but but the patient is still febrile Important Concept! o Therefore, give antip ntipyr yret etic ic round ound the the clock Pain is present o Headache o Periorbital pain o Pain behind the eyes o Joint and bone pain o Abdominal Pain Nausea and Vomiting Pres Presen ence ce of Path Pathol olog ogic ical al Vasc Vascul ular ar Changes o Petechiae o Herman’s Sign Generalized redness Flushing of the skin
INFECTED MOSQUITO ▼▼▼ BLOODSTREAM (multiplies) (multiplies) ▼▼▼ Multiple lesions in the bloodstream ▼▼▼▼ ▼▼▼▼ Increased Increased Capillary Capillary Fragility Permeability (causes easy (allows shifting bleeding; of fluid from difficult to stop one due to compartment thrombocytopenia; to poor clotting another leads to ascites; hemoconcentration
Important Concept! patient recovers, he only has If Dengue Fever (and not Dengue Hemorrhagic Fever) Dengue Fever is also called: o Dandy Fever o Breakbone Fever
Dengue
DHF Grade 1
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DHF Grade 2 If there is persistence of signs and symptoms of DHF Grade 1 If there is bleeding from: o Nose – epistaxis o Gums – gum bleeding o Vomiting of blood – Hematamesis (coffee ground appearance from the stomach) Upper Gastro-Intestinal Tract Bleeding o Melena Passing of black tarry stool Acted upon by digestive enzymes Lower Gastro-Intestinal Tract Bleeding o Hematochezia Passing of fresh blood in the stool Then, these signs and symptoms indicate the START OF HEMORRHAGIC FEVER
With shock Hypovolemic shock due to excessive blood loss due to uncontrolled bleeding
Diagnostic Tests Hemorrhagic Fever
for
Dengue
1. Tourniquet or Rumpel Leede’s Test Test for capillary fragility Concept! o This is only a presumptive test for DHF (not a confirmatory test) o Not all patients are subjected to this test Three (3) criteria that must be present before you perform the tourniquet test: o Person must be at least six (6) months old o Fever should be more than three (3) days o No other signs of DHF are present Patient only feels fever If there are other manifestations (i.e. stomachache), do not do tourniquet test How is it done? o Get the blood pressure of the patient o Add systolic and diastolic pressures o Divide the sum by two o Apply that pressure on the cuff. . . For five (5) minutes if the patient is pediatric For ten (10) minutes if the patient is an adult o Deflate the Blood Pressure Cuff o Check for the presence of petechial formation o If greater than or equal to petechial formations per square inch, then patient is positive (+) to Tourniquet Test o Therefore, patient is probably suffering from Dengue Hemorrhagic Fever To confirm the diagnosis, do the next test. . .
DHF Grade 3 Persistence of signs and symptoms of DHF Grade 2 With signs of circulatory collapse or failure With cold clammy skin Nursing Alert! o Check for capillary refill How? o Apply pressure on nailbeds Normal capillary refill time is about one (1) to two (2) seconds If capillary refill time is about three (3) seconds or more, blood flow is sluggish due to circulatory failure Check Vital Signs Indicators of Circulatory Failure: o Hypotension or decreased blood pressure Rapid but weak pulse Rapid respiration DHF Grade 4 With signs and symptoms of DHF Grade 3 25
2. Blood Examination Platelet Count o Normal value is 150,000 to 400,000 platelets per cubic millimeter o Values lower than the normal indicate that patient is positive (+) for Dengue Hemorrhagic Fever Hematocrit Determination o Measures degree of hemoconcentration o Normal value is 37% to 54% o Values higher than the normal indicate that patient is positive (+) for Dengue Hemorrhagic Fever Medical Management Symptomatic No specific treatment Important Concepts! If patient is febrile o Administer antipyretic o But never use aspirin Potentiates clumping of platelets Results to bleeding o ASA is not given to children below twelve (12) years old and when cause of disease is unknown. Side effect is Reye’s Syndrome A neurologic disorder associated with viral infection If there is bleeding Give coagulants o Vitamin K Aquamephyton Konakion Vitamin C To increase capillary resistance Provide blood transfusion Nursing Management bleeding prevention and Prioritize control For gum bleeding o Use cotton swab o This is softer than any toothbrush •
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Provide ice chips Advise patient to gargle o It will not cause injury Use mouthwash o Use soft-bristled toothbrush o Consider this as the last measure to be taken compared with the three others above Keep patient on NPO if patient vomits blood Apply ice pack over epigastric region of patient Doctor may order NGT insertion For gastric lavage, use ice cold NSS or coagulant Provide adequate nutrition Avoid dark colored foods Important Concept! Attack of Dengue Hemorrhagic Fever does not give permanent immunity Prevention: Practice CLEAN PROGRAM of the DOH MALARIA Also called Ague King of tropical diseases Manifested by indefinite periods of chills and fever Important Concepts! Microorganism is a PROTOZOA Plasmodium has four species o Plasmodium malariae o Plasmodium ovale o Plasmodium vivax One of the most common in the Philippines o Plasmodium falciparum Another of the most common in the Philippines o The most fatal due to its tendency to multiply rapidly Plasmodium is acquired through a mosquito bite – Anopheles mosquito is needed by the female Blood Anopheles mosquito for the fertilization of its eggs Important Concepts! Anopheles mosquito is o A NIGHT biting mosquito It bites from sunset to sunrise or from dusk to dawn
o
o
It breeds in CLEAR, SLOW FLOWING WATER It is common in Rural Areas Mountainous Areas Forested Areas Palawan Dumaguete Surigao It lands on the surface on a forty-five (45) degree angle or in a slanting position
Malaria can also be BLOOD TRANSFUSION Manifestations of Malaria
by
Stage 1 – Cold Stage Lasts for ten (10) to fifteen (15) minutes Chilling sensation is present Shaking, chattering of the lips is present Nursing Responsibilities o Provide warmth o Blankets o Warm drinks o Not warm compress o Hot water bag on soles of the feet Expose to heat lamp or o droplight Stage 2 – Hot Stage Last for four (4) to six (6) hours The patient has: o Fever o Headache o Abdominal Pain o Vomiting Nursing Responsibilities o Lower the body temperature o Provide tepid sponge bath o Provide cold compress o Increase fluid intake o Provide light, loose clothing o Provide antipyretic as ordered Stage 3 – Wet Stage Patient exhibits: o Profuse sweating Feeling of weakness o
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obtained
Pathophysiology of Malaria PLASMODIUM ▼▼▼ BLOODSTREAM ▼▼▼▼ ▼▼▼▼ Inside RBC (for Those that don’t reproduction) penetrate RBC go to the LIVER. They do nothing and may remain dormant for 3 – 5 years. They wait for the liver to release the RBC for them to penetrate other RBC ▼▼▼ Inside RBC
Important Concepts!!! Once inside the Red Blood Cells (RBC), the microorganism multiplies and destroys the RBC. This leads to ANEMIA! of membranes of Rupturing Plasmodium coincides with the presence of CHILLS in the patient of more or new Presence microorganisms in the bloodstream causes FEVER! Important Concepts! If you have malaria and your last attack is more than five (5) years ago, then you can be a blood donor If your last attack is less than five (5) years ago, you CANNOT BE A BLOOD DONOR
Nursing Responsibilities o Make patient comfortable o Keep patient dry and warm o Provide fluids to prevent dehydration o Make patient rest comfortably in bed Important Concepts!!! other types of sicknesses or In disorders, chills occur before fever This is due to body’s response to heat loss
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Medical Management of Malaria Anti-malarial Agents Drug of Choice o Chloroquine Other Drugs used: o Primaquine o Atabrine o Pancidar o Quinine A reserve drug for severe type of malaria Important Concepts! Anti-malarial agents are cautiously used in pregnant women They are considered as ABOTIFACIENT AGENTS o They can cause ABORTION However, this is NOT CONTRAINDICATED because if mother (infected with malaria) is not treated, the child may be born with NEONATAL MALARIA Child with Neonatal Malaria exhibits the following: o Decreased levels of RBC o Immature liver o Severe anemia Child may die Key Concepts! Malaria may be acquired through: o Blood Transfusion o Vertical Transfusion RBC passes through the placenta (not the microorganism)
In ordinary infections, higher temperatures are seen during CHILLS because patient is trying to retain heat malaria, increased temperature In occurs on FEVER or HOT STAGE There is no fever during the cold stage Chills occur due to the release of Plasmodium Key Concept! If causative agent is P. falciparum, its rapid multiplication and RBC destruction would lead to… o Anemia o Liver then compensates and results to HEPATOMEGALY o Splenomegaly o Mild jaundice sometimes occurs o Cerebral Hypoxia Restlessness Confusion Delirium Convulsions Loss of consciousness Coma o Black Water Fever Passing out black urine or dark red urine due to rapid RBC destruction This may lead to death
Diagnostic Tests for Malaria Blood Smear or Malarial Smear Best time to collect o At the HOT STAGE o At the peak of fever (this is when the microorganism is in the blood stream) Concepts! the Hot Stage, the During microorganism is in the bloodstream the Cold Stage, the During microorganism is inside the red blood cells Quantitative Buffy Coat (QBC) This is seldom done This test is expensive Specimen used is blood A rapid test for malaria You do not have to wait for fever to set in to undergo this test You can extract blood earlier
Important Concept! An attack of Malaria does not provide permanent immunity A repeat bite from a malaria mosquito is not needed because the microorganism may be dormant in the liver Prevention Practice the CLEAN PROGRAM of the DOH COMMUNICABLE DISEASES INTEGUMENTARY SYSTEM Viral Communicable Diseases Measles German Measles 28
OF
THE
Chicken Pox Herpes Zoster
o
Use of colantro discouraged
is
now
Diagnostic Tests for Measles
MEASLES Causative Agent Morbilli o Paramyxovirus Rubeola Virus Manifestations of Measles 1. Pre-eruptive Stage Three (3) C’s o Coryza o Cough o Conjunctivitis Kuplick Spots o Fine red spots with bluish white spot at the center o Found at the inner cheeks o This is the PATHOGNOMONIC SIGN of Measles Eruptive Stage Rashes are now present Maculopapular Rashes o Flat to elevated o Reddish in color o With blotchy appearance o In the vernacular, pantal-pantal o Face of the patient looks bloated o Cephalocaudal distribution Appears first on the hairline Head to toe distribution o Appears on the 3 RD DAY of illness o Within two (2) to three (3) days, the entire body will be covered with rashes 3. Post-eruptive Stage Time when rashes start to disappear Fine, branny desquamation appears Then the desquamation peels off off proceeds in a Peeling cephalocaudal manner It is only the rashes that will be peeling off, NOT THE SKIN of the patient Concept! o Use of Colantro o Has a burning effect o Causes skin to likewise peel off
Concept! There is no specific diagnostic test for measles 1.Clinical Observation Medical Management for Measles Symptomatic Management Recovery dependent on Nursing Care Nursing Care Maintain and increase body resistance of the patient Provide the following: Adequate rest Adequate nutrition o No diet restrictions o Provided that patient is not a hypersentitive individual (i.e. prone to allergies) o Seafood or poultry products are contraindicated if the patient is allergic to these foods o Increase oral fluid intake o Especially those rich in Vitamin C Keep patient’s back dry and warm o Rationale Exposure to draft gives rise to cough and cold It gives rise to a good medium for growth of microorganisms Leads to pulmonary complications like pneumonia, which could lead to death Provide hygienic measures o Eye care Measles patients have much “MUTA” To prevent eye complications o Ear care To prevent otitis media o Mouth care o Nasal care o Skin care Taking a bath or taking a sponge bath is not contraindicated 29
However, do not expose the patient to draft Other Nursing Care Symptomatic nursing care Patient is photophobic o Provide dim and quiet environment
Important Concept! Attack of measles gives permanent immunity to the disease Key Concept! When is the patient communicable? Patient is communicable before rashes appear or during the pre-eruptive stage. Preventive Measures 1. Immunization Anti-measles vaccine (AMV) When given: o Age of nine (9) months Dosage: o 0.5 cc Route: o Subcutaneous Site: o Deltoid muscle Important Instructions to be given to the mother of the patient! o Child may experience fever o Give paracetamol to lower the body temperature o After three (3) to four (4) days, child will have a rash formation. This is a NORMAL REACTION to the vaccine o In fact, it is a good reaction, indicating that the patient’s body has produced anti-bodies to measles
Ask mother if the child has allergies to egg and neomycin o MMR is made up of duck embryo and neomycin o If patient is allergic to egg Give vaccine But observe for signs and symptoms of allergies o If patient is allergic to neomycin Do NOT give MMR vaccine It may cause anaphylaxis
Important Concept! DOH Program on Measles o Ligtas Tigdas Immunization Program in 2004 Mode of Transmission Airborne Prevention Proper disposal of nasopharyngeal secretions Cover the mouth when coughing or sneezing Key Concepts!!! Measles is not fatal by itself Common complications o Bronchopneumonia o Encephalitis GERMAN MEASLES Also called: o Rubella o Three (3) day disease o Poteln Causative Agent Pseudoparamyxovirus o Rubella Virus Togavirus Mode of Transmission Droplet (not airborne)
Important Concepts! In the private setting, MMR vaccine is given… When: o Age of fifteen (15) months Dosage: o 0.5 cc Route: o Subcutaneous Site: o Deltoid muscle
Manifestations of German Measles 1. Pre-eruptive Stage Fever may be present or absent If patient has fever, it lasts only for one (1) to two (2) days Patient has mild cough and mild cold NO CONJUNCTIVITIS 30
Therefore, he only has two (2) C’s. Important Concept! o Enanthem of German Measles are called FORSCHEIMER SPOTS Fine red spots Also called petechial spots Appears on the soft palate nd 2 Stage – Eruptive Stage With maculopapular rashes o Not reddish but pinkish o Not blotchy but discreet o Appearance is fine o Slightly unnoticeable o Rashes are smaller compared with those of measles o Also has cephalocaudal distribution o Appears first at the head Important Concept! o Once the rashes appear, within twenty-four (24) hours, the entire body is filled with rashes o However, head-to-toe distribution is not as distinct as in measles Key Concepts! o Patient is positive for enlargement of lymph nodes Suboccipital lymph nodes Posterior auricular lymph nodes Posterior cervical lymph nodes o This is a differentiating factor between German Measles (positive for enlargement of lymph nodes) and Measles (negative for enlargement of lymph nodes). o
Diagnostic Tests, Medical Management, Nursing Management and Preventive Measures for German Measles are THE SAME AS THAT FOR MEASLES Important Concepts! An attack of German Measles gives permanent immunity is German Measles When communicable? o During the entire course of the disease. o Until enlarged lymph nodes return to normal German Measles is NOT FATAL It can become fatal if patient is on her first trimester of pregnancy due to chances of giving birth to a child with congenital anomalies: o Microcephaly o Congenital Defect (Tetralogy of Fallot, etc.) o Cataract leading to blindness o Deafness and mutism Mere exposure of pregnant woman to German Measles MUST BE AVOIDED o If exposed during the first trimester of pregnancy, pregnant mother must immediately receive immunoglobulin or gamma globulin within seventy-two (72) hours. After three (3) days, the virus has already passes through the placenta o Therefore, once pregnant, women should be already given gamma globulin German Measles is more fatal to pregnant women relative to Measles All people have been exposed to measles, therefore, anti-bodies to measles have already been developed. Not all have been exposed to German Measles, therefore, not all have developed anti-bodies to German Measles MMR vaccine o Measles, Mumps, Rubella vaccine
3rd Stage – Post-Eruptive Stage Rashes now start to disappear But they disappear at the third (3 rd) day of illness Important Concept! o In measles, rashes just start to manifest themselves by the third (3rd) day of the illness o Enlarged lymph nodes will gradually subside 31
o
If you are an adolescent, you can receive this but do not be pregnant within the next three (3) months because you may give birth to a child with congenital anomalies
Vesiculopustular Rashes Additional Concepts!!! These rashes are itchy Therefore, it is a MUST that the patient takes a bath DAILY If the patient does not take a bath. . . o Patient will perspire o Patient will accumulate dirt o Dirt + Wetness + Itchy rashes will lead to greater itching and would eventually result into SCRATCHING Scratching may be avoided while the patient is awake However, scratching during sleep is common among Chicken Pox patients Key Concept! Do not scratch rashes Scratching results to infection or pox marks!!!
CHICKEN POX Also called Varicella Causative Agent Varicella Zoster Virus o Can be found both on: Nasopharyngeal Secretions Secretions of rashes But only causes infection if. . . o It enters the nasopharynx o Does NOT cause infection by skin to skin contact Mode of Transmission Airborne
SCRATCHING WHILE ASLEEP ▼▼▼ RUPTURES THE VESICLES ▼▼▼ ▼▼▼ Leads to skin Permanent Infection Scar ▼▼▼ (Pox mark) Becomes a Boil, or a Furuncle (big Boil), or a Carbuncle (several boils attached to one another) ▼▼▼ Results to cellulitis or gangrene Important Concepts: The distribution of the rashes are: o Generalized o Found all over the body Found first on the trunk Found on the covered parts of the body Then found on the scalp Abundantly found on the covered parts of the body and then on the exposed parts of the body Key Concept! Period of Communicability
Three (3) Stages of Manifestation Stage 1 – Pre-Eruptive Stage Presence or absence of low-grade fever Headache Body malaise Muscle pain Lasts for twenty-four (24) to fortyeight (48) hours Stage 2 – Eruptive Stage Presence of rashes o Vesiculopustular rashes of Vesiculopustular Development Rashes: o Initially, these rashes are macules – FLAT RASHES o They will become elevated or become PAPULES o Then, another set of macules appear o The original rashes (now papules) will become vesicles o Pus then develops Important Concept! o It is only during the eruptive fever stage that you can see all the following: Macules Papules Vesicle 32
Until the LAST RASH has crusted!!! o Easily and highly-contagious upon the appearance of rashes Important Concepts! During the summer season, if you have not had chicken pox and if you are immunocompromised, DO NOT GO OUT Duration of the Disease o Two (2) weeks Important Characteristic of Chicken Pox Rashes Rashes have UNIFOCULAR appearance They have one focus Rashes appear one at a time and they NEVER FUSE TOGETHER There is always a gap between one rash to another rash o If rashes get into contact with each other, it is no longer Chicken Pox. o It is HERPES ZOSTER
o
Zovirax may be effective but it does not allow the patient to produce antibodies. Therefore, let the normal course of Chicken Pox occur
Nursing Care for Chicken Pox Same as in measles But more focus should be given on SKIN CARE o Rationale: To prevent skin infection Complication is encephalitis Important Concepts! of Chicken Pox gives Attack permanent immunity Period of Communicability o Until last rash has crusted Preventive Measures 1. Immunization Varivax o Varicella Vaccine Dosage o 0.5 cc Route o Subcutaneous For children below thirteen (13) years old o Single dose is given o Site of administration is the deltoid muscle For those thirteen (13) years old and above o Two doses are given o With one (1) month interval
3rd Stage – Post-Eruptive Stage Rashes now start to crust They start to dry They start to peel off If rashes start to dry, let them peel off by themselves If allowed to dry and peel off, there will be no infection However, it leaves a pox mark Diagnostic Test for Chicken Pox Clinical Observation Medical Management of Chicken Pox management as Symptomatic causative agent is a virus Additional Concepts! Zovirax or Acyclovir o Not a treatment for chicken pox o Virus is not always responsive to this drug o Some viruses are resistant (drug has no effect) while some are sensitive to it and patient will heal within three (3) days Dosage is four (4) to five (5) o tablets per day for one week Zovirax Cream o Protects skin from infection but does not protect against pox marks
2.Proper disposal secretions
of
nasopharyngeal
3.Cover nose and mouth when sneezing or when coughing Important Concepts! Not all of the Chicken Pox virus would leave your body. Some are left behind, travel to the nerve and become dormant Therefore, next exposure to it will not give you Chicken Pox New Varicella Zoster Virus will go to the nerve and activate dormant virus to give you Herpes Zoster 33
Herpes Zoster is the dormant or inactive type of Chicken Pox You CANNOT have Herpes Zoster until you have obtained Chicken Pox Adults usually affected by Herpes Zoster because what is affected is the ganglion of posterior nerve root
To decrease chances of skin infection Oxidizing effect To deodorize the rashes and remove the fishy odor Important Concept! An attack of Herpes Zoster does not give permanent immunity Most common complications of Herpes Zoster o Skin infection o Encephalitis Preventive Measures Same as that of Chicken Pox Important Concepts!!! Children are mostly affected in: o German Measles o Measles o Chicken Pox Adults are mostly affected in: o Herpes Zoster •
•
HERPES ZOSTER Also called o Shingles o Zone o Acute Posterior Ganglionitis Causative Agent Varicella Zoster Virus Mode of Transmission Droplet Manifestations of Herpes Zoster Same as those of Chicken Pox Rashes are also vesiculopustular However, there are differences in the characteristics of rashes Herpes Zoster rashes are: o Not itchy o More of painful because nerves are affected o Even if patient has recovered and rashes are long gone, pain may be persistent up to two (2) months. This is NORMAL o Rashes do not have generalized distribution o Has a unilateral distribution because it follows the nerve pathway o Always vertical or longitudinal (on one side) o Rashes do not have unifocular appearance but APPEARS IN CLUSTERS Diagnostic Test and Medical Management for Herpes Zoster Same as in Chicken Pox Additional Medical Management Application of Potassium Permanganate (KMnO4) compress over the rashes of the patient Rationale: o To obtain three-fold effect Astringent effect To dry the rashes Bactericidal effect
COMMUNICABLE DISEASES OF THE RESPIRATORY SYSTEM Bacterial Diphtheria Pertussis Tuberculosis Pneumonia Viral Colds Influenza Causative Agent Corynebacterium diphtheriae (Klebs-Loeffler Bacillus) This bacteria does not only affect the respiratory tract o If it affects the mucous membrane, this is called CUTANEOUS DIPHTHERIA Types of Cutaneous Diphtheria o Conjunctival Diphtheria Conjuctiva is affected o Vaginal Diphtheria Vaginal mucosa is affected o Diphtheria of the Prepuce Affectation of the uncircumcised prepuce of the male
•
34
o
Wound Diphtheria Affects wounds Especially of patients
Like cigarette ash also has a BULL NECK Patient appearance o Enlargement of the neck o Specifically of the anterior upper aspect of the neck o This is due to inflammation and enlargement of cervical lymph nodes o Anterior upper aspect of the neck is: Reddish Warm to touch There is pain Tenderness The difference between a person with Pharyngeal Type of Diphtheria and a person with double chin is that double chin people have on their necks: o Normal skin color o Normal temperature o No pain 3. Laryngeal Type Affects the larynx or the voice box With hoarseness of voice With loss of voice o Aphonia but only temporary Larynx also serves as airway passage o Therefore, there is: Dyspnea Difficulty of breathing compensates and uses Body accessory muscles Important Concepts! Overuse of accessory muscles results to chest retractions or chest indrawing Important Concepts!!! Normally, when a person breathes in, the chest expands But with over usage of accessory muscles, chest wall does not expand, rather, it DRAWS IN!!! In order to detect chest indrawing, look at the subcostal area (lower area of the chest region). This elevates due to severe dyspnea Do not look at the sternum or at the intercostals spaces Check for chest indrawing when: o The patient is calm o The patient is not crying o
burn
Important Concepts! Respiratory Diphtheria o Is the more common type of diphtheria Wound Diphtheria o Is the rare type of diphtheria Mode of Transmission Droplet Manifestations of Diphtheria Depends upon its classification Three (3) Types of Respiratory Tract Infections 1. Nasal Type Nasal passages are affected With irritating nasal discharge o Characterized by serosanguinous secretion with foul mousy odor (whitish, bloody, smells like a rat) Due to rubbing of nose, this results to upper lip and nasal excoriation Pathognomonic Sign o Presence of pseudomembrane o However, not appreciable in the NASAL TYPE o This is found within the nasal septum o Speculum is needed o But is usually covered by irritating nasal discharge 2. Pharyngeal Type or Faucial Type Affects the pharynx and the tonsils Patient complains of: o Sore Throat o Dysphagia Presence of pseudomembrane, which is visible upon opening of the mouth Pseudomembrane is present on the following: o Soft palate, o Uvula o Pillars of the tonsils The pseudomembrane can be described as: o Grayish-white membrane
•
35
The patient is not breastfeeding (chest indrawing is NORMAL under this condition) o The patient is bottle-feeding (chest indrawing is NORMAL under this condition) Chest indrawing is constant in a patient with diphtheria Chest indrawing is always present in any position in a patient with diphtheria Important Concepts!!! Pseudomembrane is also present o Present in the larynx o Laryngoscope is needed to see the pseudomembranes Pseudomembranes may trigger cough Characteristics of cough: o Barking cough o Dry o Metallic o Croupy o Husky Due to hoarseness of voice Key Concept! Laryngeal Type of Diphtheria may become severe
Test to determine hypersensitivity to diphtheria toxin Nose and Throat Swab Most commonly done test Confirmatory Test o To identify the microorganism o To determine if patient is still communicable Important Concept! o Patient is still communicable until three (3) consecutive results of negative (-) nose and throat culture are obtained Medical Management for Diphtheria Three (3) Objectives:
o
LARNGEAL TYPE OF DIPHTHERIA ▼▼▼ Laryngeal Edema ▼▼▼ Airway Obstruction ▼▼▼ Respiratory Obstruction ▼▼▼ Respiratory Distress ▼▼▼ Death Therefore, management is EMERGENCY TRACHEOSTOMY Among the three types of Diphtheria, Laryngeal Diphtheria is the most fatal due to the possibility of respiratory obstruction, which may lead to death.
Diagnostic Tests for Diphtheria 1. Schick’s Test Test for immunity or susceptibility to diphtheria 2. Moloney Test 36
1. Neutralize the toxin toxin brings about systemic The effects Therefore, give anti-diphtheria toxin o Do skin test first o If positive for the skin test Give drug Because there is no Diphtheria Ig But give in fractional doses have ready and handy the Also following: o Epinephrine o Corticosteroid 2. Kill microorganism Give anti-biotics Drug of Choice o Penicillin Important Concept! Scraping the pseudomembrane does not kill the microorganism It only causes bleeding 3.Prevent Respiratory Obstruction of emergency Performance tracheostomy Nursing Management for Diphtheria 1. Place patient on complete bed rest until two (2) weeks after recovery Rationale: o To prevent the number one complication – MYOCARDITIS o Myocarditis leads to death
Toxin released by microorganism has special affinity for heart muscles o Toxin released travels to the bloodstream o Goes to the heart o Waits for opportunities when heart’s resistance to go down: When the heart is overloaded with work When the heart is under stressful activities Therefore, provide COMPLETE BED REST o
Signs and Symptoms of Myocarditis Marked facial pallor Very irregular pulse rate Hypotension Chest pain or epigastric pain Important Concept! When the above signs and symptoms are observed, immediately seek consultation 2. Maintenance of Patent Airway Proper position of patient o Upright o Semi-Fowler’s Encourage Deep Breathing Exercises and coughing exercises with pursed lip Chest Physiotherapy Increased oral fluid intake to liquefy the secretions Frequent turning to sides to prevent pooling of secretions Do inhalation therapy with doctor’s order. o Nebulization o Steam Inhalation Postural Drainage with Perform doctor’s order If patient cannot expectorate, suction secretions as needed 3. Provide adequate nutritious diet Soft diet due to the presence of dysphagia 4. Other nursing managements are symptomatic and supportive Important Concept!!! An attack of diphtheria does not provide permanent immunity since the causative agent is a bacteria
Preventive Measures 1. Immunization DPT vaccine 2.Proper disposal of nasopharyngeal secretions 3. Cover the nose and the mouth when sneezing or coughing 4. Never kiss the patient. Diphtheria affects all ages Common in children PERTUSSIS Also called o Whoofing cough o Chin cough Only affects children below six (6) years old Causative Agent Cocobacillus Both aerobic and anaerobic o Bordatella pertussis o Haemophilus pertussis Mode of Transmission Droplet Manifestations of Pertussis Three (3) Stages
1. Catarrhal Stage Highly contagious Colds Nocturnal coughing o Coughing is present at night Fever Tiredness Listlessness 2. Paroxysmal or Spasmodic Stage With five (5) to ten (10) successive, forceful coughings, which ends on a prolonged inspiratory phase or a WHOOF To loosen mucous plug on airway (this causes the patient to cough) To loosen thick and tenacious secretions Therefore, child coughs for five (5) to ten (10) times patient is unsuccessful in When expectorating narrow passageway requires long inhalation If patient keeps on coughing o He may choke on his mucous This results to vomiting o 37
Therefore, the patient is positive for vomiting Due to pressure exerted on vomiting, there could be o Congested face (bloated face) o Congested tongue Purple in color Due to pressure exerted on the tongue by the teeth when coughing o Teary-red eyes with protrusion due to pressure exerted when coughing o Distention of face and neck veins o Involuntary micturition and defecation o Abdominal hernia due to pressure exerted on abdominal wall when coughing If patient is vomiting: o Metabolic alkalosis occurs This will trigger convulsions due to electrolyte imbalance Convalescent Stage Patient is no longer communicable Signs and symptoms will now start to subside Patient is now on the road to recovery o
o
Mucolytics are allowable
Nursing Management for Pertussis 1. Complete Bed Rest To conserve the energy of the patient Decreases oxygen demand Decreases oxygen consumption 2. Prevent Aspiration Proper position of patient o Upright position in feeding During spasmodic attacks of cough o Hold all feedings and keep patient on NPO (nothing per orem) For children below six (6) years old: o If bottle-fed Inform mother that nipples in bottle should only have a SMALL BORE to lessen chances of aspiration o Feed child with a medicine dropper 3. To manage vomiting: Monitor Intake and Output Assess for signs of dehydration Provide proper I.V. regulation Provide adequate fluids with extra aspiration precaution 4.Application of Abdominal Binder To prevent abdominal hernia Important Concept! immunity from an No permanent attack of Pertussis is acquired. However, second attacks are rare. Age decreases risks Preventive Measures Same as for Diphtheria But you can kiss the patient because you (adults) are above six (6) years old (in Diphtheria, all ages are affected)
Diagnostic Tests for Pertussis 1. Nasal Swab 2. Bordet-Gengou Test Specimen is nasopharyngeal secretion 3. Agar Plates Specimen is nasopharyngeal secretion 4. Cough Plate Specimen is nasopharyngeal secretion Medical Management Anti-biotic Treatment o Drug of Choice Erythromycin Pertussis Immune Globulin For nocturnal cough o Give mild sedation Replace fluids and electrolytes lost due to vomiting Important Concept!!! o No expectorant should be given to pertussis patient o This stimulates coughing
TUBERCULOSIS Also called o Koch’s infection o Phthisis o Galloping Consumption o Pulmonary Tuberculosis Causative Agent Mycobacterium tuberculosis 38
1. According to Extent of Disease Basis is on the CAVITATIONS IN THE LUNGS as seen through Chest X-ray o Minimal Pulmonary Tuberculosis o Moderately Advanced Pulmonary Tuberculosis Far Advanced Pulmonary o Tuberculosis 2. According to CLINICAL MANIFESTATIONS Basis is the presence or absence of clinical manifestations o Active Pulmonary Tuberculosis Infected; with signs and symptoms o Inactive Pulmonary Tuberculosis Infective; without signs and symptoms; with medication 3. According to American Pulmonary Society
Acid-fast bacteria o Also known as tubercle bacilli Mode of Transmission Airborne (most common) Important Concept! Therefore, there is no need to separate eating utensils! Tuberculosis is not acquired through shared utensils. Tuberculosis is also acquired through ingestion of contaminated milk o Causative agent is Mycobacterium bovis or Mycobacterium bovine o Tuberculosis of Cattle o From improperly pasteurized or improperly boiled milk Tuberculosis may also be acquired from birds o Mycobacterium avium is the causative agent o Obtained when taking care of infected bird o Eating of the bird is not necessary to get infected Mycobacterium avium Complex o Most common opportunistic infection for AIDS patients in the United States Important Concept! Patients infected with Tuberculosis bacilli are most of the time asymptomatic Symptoms are usually seen after four (4) to eight (8) weeks. o
TB0
Negative ( - ) to TB exposure Negative ( - ) to TB infection Negative ( - ) to TB testing Newborns are under this classification They are given preventive management in the form of BCG vaccine immediately after birth
TB1
Manifestations of Tuberculosis Afternoon low-grade fever with night sweats Anorexia Weight loss Fatigability Body malaise Chest pain / back pain Positive for productive cough Hemoptysis Difficulty of Breathing Anemia Amenorrhea in females
Positive ( + ) to TB exposure Negative ( - ) to TB infection Negative ( - ) to TB testing Medical and other healthcare workers are under this classification They are given preventive management in the form of Personal Protective Equipment (PPEs); and increased body resistance through vitamins, adequate rest and adequate hand washing
TB2
Three (3) Classifications of Patients
39
Positive ( + ) to TB exposure Positive ( + ) to TB infection Positive ( + ) to TB testing Negative ( - ) to TB symptoms Inactive PTB patients and carriers are under this category They are given prophylactic management so that they would not exhibit signs and symptoms Start on Anti-Tuberculosis drugs
INH o Isoniazid The most effective TB drug Side Effect Peripheral Neuritis Give Vitamin B6 or pyridoxine to counteract INH side effect Increase Vitamin B6 by intake of: o Beans Mongo Red beans White beans Black beans o Prophylaxis is given for six (6) months For children o Prophylaxis is given for nine (9) months For Immunocompromised patients o Prophylaxis is given for twelve (12) months
o
•
Nursing Management o Therefore, monitor liver enzyme tests Advise patient to avoid alcoholic beverages, which increase hepatotoxic effects
Key Concept! Rifampicin Side effects are: o Orange urine o Orange tears o Orange secretions and excretions o Orange saliva o Orange sputum o Orange feces Nursing Management o Inform the patient that this normally happens o Therefore, remove soft contact lenses These may be permanently stained with orange color o Advise the patient to use eyeglasses instead Isoniazid Side effect is peripheral neuritis
TB3 Positive ( + ) to TB exposure Positive ( + ) to TB infection Positive ( + ) to TB testing Positive ( + ) to TB symptoms Active PTB patients are under this classification They are given curative management of Anti-Tuberculosis Combination drugs to prevent drug resistance Short-Course Chemotherapy Composed of RIP(E) o Rifampicin Isoniazid Pyrazinamide Ethambutol May or may not be given Standard Regimen o Composed of SI(E) Streptomycin Isoniazid Ethambutol May or may not be given Important Concepts!!! Short-Course Chemotherapy Side Effects Causes hepatotoxicity
Nursing Management o Give Vitamin B6 or pyridoxine Pyrazinamide PZA Side effect is hyperuricemia is predisposed to stone Patient formation Therefore, make urine alkaline Nursing Management o To alkalinize the urine o Increase fluid intake o Increase intake of vegetables Ethambutol Side effect is Optic Neuritis o Causes color blindness or inability to distinguish red from green Nursing Management o IMMEDIATELY STOP the medication because this side effect is IRREVERSIBLE Important Concepts!!! Standard Regimen
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40
Streptomycin o No hepatotoxicity o But causes RENAL TOXICITY o Nursing Management o Monitor the following: Creatinine levels Blood Urea Nitrogen (BUN) levels Monitor Intake and Output o Also causes OTOTOXICITY o Nursing Management o Assess patient for tinnitus or ringing of the ears o Assess patient for vertigo, which is another sign indicative of ototoxicity Key Concept! American Pulmonary Society The classification is the best classification!!!
Diagnostic Tuberculosis
Examinations
Utilizes the same technique as a skin test Uses PPD Interpreted after forty-eight (48) to seventy-two (72) hours result is bigger wheal Positive induration 1.2) Tine Test or Multi-puncture Test Soak sterile needle in PPD for three (3) to four (4) hours Get arm Puncture for six (6) to eight (8) times in a circular manner This is commercially prepared This utilizes a special syringe with four (4) small needles for one simultaneous application 1.3) Vollmer and Pirquet Test Skin scratch or skin patch test Get sterile needle Get gauze containing PPD Apply this gauze over the scratch or tape this gauze over the scratch Keep gauze on for seventy-two (72) to ninety-six (96) hours Remove after three (3) to four (4) days Results cannot be interpreted yet Wait for another forty-eight (48) to seventy-two (72) hours Therefore, results could be obtained after five (5) to seven (7) days!!! Important Concept! Mantoux Test is the best type of test!!! o Easier to perform o Less pain to patient o Most accurate results
for
1. Tubercullin Testing This is only a screening test for Tuberculosis If result is positive ( + ), it does not mean that the person is infected but the person may have an exposure If result is CONSISTENTLY POSITIVE, it means that the patient is sensitive to the organism Important Concepts!!! o This test uses Purified Protein Derivative or PPD o PPD is administered intradermally o Tubercullin testing is interpreted after forty-eight (48) to seventy-two (72) hours A positive result would give you o an induration of greater than ten (10) mm. o If patient is positive for HIV, a positive result would give the patient an induration of greater than five (5) mm Three (3) Ways of Performing Tubercullin Testing 1.1) Mantoux Test Just like a skin test 41
2. Sputum Examination This is the CONFIRMATORY TEST for Tuberculosis Done in the morning upon rising before oral care Collection of Sputum o Do deep breathing exercises for three (3) times o Open mouth widely o Put tongue at the back of the lower teeth o As the back of tongue curves upon spitting, phlegm goes out Key Concept!!!
Continuous receipt of anti Tuberculosis drugs for two (2) weeks will give the patient a negative ( - ) result o Therefore, patient is no longer communicable 3. Chest X-Ray Shows extent of lung involvement Does not reveal causative agent Not a confirmatory examination o
Give paracetamol o On site of injection, there will be an abscess formation, which will develop into a scar within two (2) to three (3) months o If after three (3) months, abscess is still present, this is called an INDOLENT ABSCESS caused by: Wrong technique Given subcutaneously instead of intradermally Child’s exposure to a person with TB (i.e. mother who is asymptomatic) Nursing Management o Bring the child to the health center or clinic for INCISION DRAINAGE o Then give prophylactic INH for nine (9) months o
•
Medical Management for Tuberculosis Short-Course Chemotherapy Standard Regimen Nursing Care for Pulmonary Tuberculosis Diet Drugs o Most important Rest Important Concept! Do not perform Chest Physiotherapy on PTB patient This can stimulate or aggravate the following: o Hemoptysis o Frank Bleeding Key Concept! An attack of PTB only gives temporary immunity
•
Additional Concepts!!! At school entrance Give booster dose of BCG When given: o About six (6) to seven (7) years old Dosage of Booster Dose o 0.01 cc Route of Booster Dose: o Intradermal Site of Booster Dose o Left Deltoid muscle Important Concepts!!! o No abscess formation on site of booster dose o Site depends on preference of the mother in a private setting Preventive Measures (continued) 2.Proper disposal of nasopharyngeal secretions 3. Cover nose and mouth when sneezing or coughing 4. Proper pasteurization of milk PNEUMONIA Inflammation of the lung parenchyma Caused by several organisms Causative Agents: Virus o Cytomegalovirus
Preventive Measures 1. Immunization Calmette Guerin (BCG) Bacillus vaccine Number of Doses: Two o When Given: o 1st Dose – At Birth o 2nd Dose – Upon school entrance Dosage of First Dose o 0.05 cc Route of First Dose o Intradermal Site of First Dose o Right deltoid muscle Important Concepts!!! o Do not massage site of injection o Rationale: It will spill the drug o Child may experience fever Nursing Management 42
In Children: If two (2) weeks to two (2) months old (1 month and 29 days) o Cut off is sixty (60) breaths per minute o If respiratory rate is 61 breaths per minute and above, this is indicative of Pneumonia If two (2) months to twelve (12) months o Cut off is fifty (50) breaths per minute o If respiratory rate is 51 breaths per minute and above, this is indicative of Pneumonia If twelve (12) months to five (5) years o Cut off is forty (40) breaths per minute o If respiratory rate is 41 breaths per minute and above, this is indicative of Pneumonia Therefore, if there is fast breathing, automatically, it is Pneumonia Home management involves antibiotic therapy Important Concept! for the presence of the Check following: o Chest Indrawing o Stridor Harsh breath sound heard during inspiration To check, place ear on nose or mouth of patient o Cough If these three signs are present, then there is SEVERE PNEUMONIA
Common opportunistic infection in AIDS
Protozoa o Pneumocystis carinii Pneumonia Also a common opportunistic infection in AIDS Bacteria o Most common cause o Can be caused by primary infection o Can be secondary to previous infection: A complication A debilitating disease Mode of Transmission Droplet Manifestations of Pneumonia Five (5) Cardinal Signs of Pneumonia 1. Fever 2. Shaking Chills 3. Sputum Production o Rusty sputum o Depends on causative agent o If sputum is creamy yellow Causative agent is Staphylococcus o If sputum is currant jelly Causative agent is Klebsiella o If sputum is clear There is no infection This may also be brought about by ASPIRATION PNEUMONIA Important Concept! o Lipid Pneumonia Occurs when oil is used in cleaning the nose Oil is not absorbed by the lungs Therefore, do not use oil-based lubricants in nasogastric tubes. 4, Productive Cough 5. Presence of Chest Pain or Pleuritic Pain Aggravated when coughing o o Use of chest binder is encouraged Important Concepts!!! Presence of fast breathing is common in Pneumonia
Diagnostic Tests for Pneumonia 1. Chest X-ray Expect infiltrations Lung consolidation This is the confirmatory examination 2. Sputum Examination is to know what Purpose microorganism brought pneumonia 3. Auscultation For crackles For ronchi o Decreased vocal fremitus ‘Ninety-nine’ verbalized o Decreased breath sounds 43
4. Percussion Dullness upon percussion Medical Management Depends on causative agent If viral o Symptomatic management If protozoal (PCP) o Drug of choice is Pentamidine If bacterial o Administer anti-biotics o In the hospital setting, drug of choice is Penicillin o In the community setting, drug of choice is Cotrimoxazole (administered T.I.D.)
Salmonella Newport o For food poisoning or salmonellosis Staphylococcus enterococcus o For staphylococcal food poisoning Clostridium botulinum o For botulism Shigella dysenterieae o For shigellosis o For bloody flax o For bacillary dysentery Vibrio coma or Vibrio cholera o Coma-shaped o Cholera or El tor o Give rise to violent dysentery due to violent diarrhea (which occurs continuously) Mode of Transmission Fecal – Oral route Source of Infection Food Water If food poisoning: Salmonellosis o Foods rich in protein Meat products Poultry Eggs Cheese Milk o Incubation Period Six (6) to eight (8) hours o Then you manifest the symptoms Staphylococcal o Carbohydrate-rich foods Cereals Rice Pastries Bread Cakes Pasta Noodles o Incubation Period Two (2) to six (6) hours o Then you manifest the symptoms Botulism o Caused by canned or preserved foods
Nursing Care for Pneumonia Patients Priority o Ineffective airway clearance Management o Maintain patent airway o Adequate rest o Adequate nutrition Preventive Measures 1. Immunization Pneumovax prevention of secondary For pneumonia Given to adults Given to the elderly with CommunityAcquired Pneumonia (CAP) 2. Proper secretions
disposal
of
nasopharyngeal
3. Cover the nose and mouth while coughing or sneezing
COMMUNICABLE DISEASES GASTROINTESTINAL TRACT
OF
THE
Bacterial Gastroenteritis Inflammation of the gastric mucosa and the mucosa of the intestines Key Concepts! Sign and Symptom of Main Gastroenteritis is diarrhea Diarrhea is a general term caused by various microorganisms Causative Agents: Salmonella typhosa o For typhoid fever 44
Incubation Period Eight (8) to twenty-four (24) hours o General manifestation is diarrhea o Borborygmi is present Gurgling sound on the abdomen Typhoid Fever o Three (3) Clinical Features o 1. Rose spots This is the PATHOGNOMONIC SIGN for typhoid fever o 2. Ladder-like fever o 3. Splenomegaly Dysentery o Characteristics of Stool o If Bacillary Dysentery Mucoid Stool Which could become blood streaked if severe Microorganism’s endotoxin destroys the intestinal wall o
If Cholera Rice-watery stool, which is one after the other The microorganisms do not destroy the intestinal wall They only stimulate peristalsis Rapid dehydration occurs o Manifested by washer woman’s hand Decreased skin integrity Poor skin turgor Very dry Nursing Management o Patient is placed on a special bed called the WATEN BED – bed with a hole o Pail is positioned underneath the hole on the bed o Bed pan is not advised o Continuous diarrhea makes the bedpan inadequate in containing all the fecal material o Vomiting also contributes to dehydration o
Number 1 indicator of dehydration in a patient with diarrhea is LOSS OF WEIGHT o This occurs within or before forty-eight (48) hours Other manifestations of dehydration, which are seen after forty-eight (48) hours are: o Thirst o Sunken eyes o Sunken fontanelles o Poor skin turgor
Diagnostic Tests Gastroenteritis
for
Patients
with
1. Stool Examination Most common diagnostic examination For Typhoid Fever o Stool examination is not a good test o Blood examinations are done o Blood culture is also done to identify the microorganism o Done during initial manifestation of the disease In the Philippines, the WIDAL TEST is done for Typhoid Fever o The antigen is detected o Antigen O Somatic antigen If present, the patient is positive for infection o Antigen H Flagellar antigen If present, patient has been previously exposed to typhoid fever or immunization In TYPHIDOT, a blood examination is conducted and an antibody is detected 2. Rectal Swab If patient is positive for gastroenteritis Medical Management for Gastroenteritis 1. Fluid and electrolyte replacement Oresol I.V. fluid Gatorade 2. Antibiotics In typhoid fever, the drug of choice is CHLORAMPHENICOL
45
This drug gives rise to bone marrow depression, which leads to anemia and even leukemia dysentery, particularly bacillary In dysentery, the drug of choice is COTRIMOXAZOLE In cholera, the drug of choice is TETRACYCLINE Important Concepts on the Administration of Tetracycline Tetracycline should not be given with the following: o Milk or calcium-rich foods o Antacids o Iron-preparation medication For better Tetracycline absorption o Give Tetracycline with one full glass of water This drug should not be given to children below eight (8) years of age because it causes staining of teeth This drug is not given to pregnant women o It is TERATOGENIC to bone growth of the fetus because it binds to calcium Once Tetracycline is expired, discard it because it will increase the toxic effect of the drug It must be kept away from sunlight It must be placed in an amber bottle destroys component of Sunlight tetracycline Important Concept! Gastroenteritis attack does not give permanent immunity o
Avoid eating in unsanitary places Fingers o Hand washing Flies o Eradicate o Environmental Sanitation o Insecticide o Screening Fomites o Do not put anything into your mouth o Most common is the ball pen o
LEPTOSPIROSIS Also called o Mud Fever o Swamp Fever o Canicola Fever o Pre-tibia o Weil’s Disease o Swine Herd’s Disease o Ictero-hemorrhagic disease A disease of a low form of animal found in the farm RATS ▼▼▼ Source of Infection Excreta of Rats Urine of Rats ▼▼▼ Causative Agent (Spirochetes) Leptospira canicola Leptospira interrogans (most common in the Philippines – infects rats) Leptospira hemorragica
Preventive Management 1. Immunization CDT immunization Given only free during epidemic Provides six (6) months immunity
Mode of Transmission Skin penetration Important Concept! No need to have a break in the skin or to have a wound to have leptospirosis
2. Avoid the five (5) Fs Usual source of infection are the Five (5) Fs: Feces o Proper excreta disposal Food o Proper food preparation o Proper food handling o Proper food storage
Individuals who are High-Risk for Leptospirosis: Sewage Workers o Those working in drainage systems Farmers Miners 46
Slaughterhouse workers (pigs, cattle are sources of infection) Manilenos o Due to flooding Incidence of leptospirosis increases during the rainy season
o
o
o
Key Concepts! When the microorganism enters, it travels along the bloodstream It affects other organs o Striated Muscles o Liver o Kidneys Spirochetes have a special affinity here They destroy the nephrons o Most common complication of Leptospirosis, which brings about death is Kidney Failure
Leptospira Agglutination Test (LAT) Leptospira Antigen-Antibody Test (LAAT) Microscopic Agglutination Test (MAT) Reveals the microorganism
Medical Management of Leptospirosis Anti-biotics Drug of Choice is TETRACYCLINE patient does not tolerate If Tetracycline, give Penicillin instead Important Concepts on Penicillin If given per orem: Give one (1) hour before meals or two (2) hours after meals o It binds with food and becomes digested o When this happens, it will be metabolized and would have no effect o Therefore, it is best to give Penicillin on an empty stomach Do not give with fruit juices or citrus juices o These juices destroy the component of Penicillin o Therefore, give with a full glass of water!!!
Manifestations of Leptospirosis Fever with chills Presence of intense itchiness of the conjunctiva Abdominal Pain Nausea and Vomiting Muscle tenderness and pain on the calf muscle (gastrocnemius) o Therefore, the patient does not like to walk or stand ictero-hemorrhagic type of For leptospirosis: o Jaundice Hemorrhages on skin and o mucous membrane
Nursing Management for Leptospirosis Symptomatic and supportive Monitor urine output due to possible kidney failure Immediately refer to doctor for any signs and symptoms of kidney failure
Important Concept! Pathognomonic sign of leptospirosis are the orange eyes or orange sclera of the eyes
Preventive Measures rats by environmental Eradicate sanitation o Use of rat poison Avoid walking through flooded areas o Wash with soap and running water after walking in floods MUMPS Infectious parotitis
Important Concept! If the kidney is affected, there would be signs and symptoms of kidney failure: Decreased urine output o o Leading to anuria Diagnostic Tests for Leptospirosis Blood Examinations
Causative Agent Paramyxovirus 47
Found on the saliva of the infected individual Mode of Transmission Droplet Manifestations of Mumps High-grade fever Earache o Ear pain Pain upon mastication or chewing Swelling of the parotid glands Diagnostic Tests for Mumps Clinical Observation Medical Management for Mumps as the causative Symptomatic organism is viral Recovery depends on nursing care provided o
If mumps is on the right side, orchitis is also on the right side o If mumps is on the left side, orchitis is also on the left side o If mumps is bilateral, orchitis is also bilateral 3. Provide adequate nutrition Provide the following types of diet: o Soft diet Because there is pain upon chewing o Bland diet Sour and spicy foods are irritating They increase salivation and increase pain Thus, kalamansi is contraindicated for mumps patients o Apple juice and water are allowed in mumps patients o
Nursing Care for Mumps Patients 1. Provide Complete Bed Rest (CBR) until swelling subsides Rationale: o To prevent glandular complications: o In Females: Oophoresis or inflammation of the ovaries o In Males: Orchitis or inflammation of the testes 2. For males, wear well-fitted supporters to prevent pulling of gravity on the testes and blood vessels. Rationale: o This predisposes the patient to orchitis and atrophy leading to sterility Important Concepts! complications are Glandular manifested only by: o Adolescents o Adults In people twelve (12) years old and above, there is complete descent of the testes into the scrotal sac Therefore, there is greater pull of gravity on the patient Glandular complications are absent among Children If orchitis is positive, its location depends on the location of the mumps 48
4. Apply ice cap or ice cooler to relieve pain Cold application deadens the nerve endings temporarily This results to numbness Important Concept! Aniel (composed of vinegar and dye) has a cold effect that decreases pain This is colored blue so that the person with mumps could be easily identified while he is still far away Key Concept! attack gives permanent Mumps immunity When is the person with Mumps communicable? o He is communicable until swelling subsides o Highly-contagious two (2) days after onset of swelling Preventive Measures Immunization o MMR vaccine Proper disposal of salivary secretions Cover nose and mouth while coughing and sneezing COMMUNICABLE DISEASES OF THE GASTROINTESTINAL TRACT AND ITS ACCESSORY ORGANS
Individuals AT RISK for Hepatitis A: Those living in unsanitary conditions Those who practice anal – oral sex Incubation Period: Two (2) to six (6) weeks
HEPATITIS Inflammation of the liver Brought about by several causes: o Alcoholism o Drug intoxication Hepatotoxic Drugs Anti-Tuberculosis drugs Tylenol Acetaminophen o Chemical Intoxication Arsenic Microorganisms o Viral Communicable microorganisms Important Concept! Current Number of Viruses causing Hepatitis Capable of Infecting Humans o Hepatitis A virus o Hepatitis B virus o Hepatitis C virus o Hepatitis D virus o Hepatitis E virus o Hepatitis G virus Non-pathogenic in Man o Hepatitis H HEPATITIS A Also called: o Infectious Hepatitis o Catarrhal Jaundice Hepatitis o Epidemic hepatitis Incidence is in epidemic proportions Causative Agent Hepatitis A virus o RNA-containing virus Important Concepts! In Hepatitis A infected individuals: o The feces Harbors the microorganism in abundant amounts o The blood Harbors the microorganism in minimal amounts Mode of Transmission Fecal – Oral Transmission percutaneous or by blood Rarely transmission
HEPATITIS B Also called: o Serum Hepatitis o Homologous Hepatitis o Viral Hepatitis The most fatal form of hepatitis The most fulminant form of hepatitis Causative Agent Hepatitis B virus o DNA-containing virus Important Concept! In Hepatitis B infected individuals o The Blood Harbors the microorganism o Other body fluids Tears Saliva Sweat Cerebrospinal Fluid Milk Urine Semen o In fact, all fluids Harbor the microorganism Mode of Transmission Percutaneous Use of contaminated sharps and o needles o Blood Transfusion Oral to oral Transmission o In saliva Sexual Transmission o Seminal fluid o Cervical fluid Vertical Transmission Swallowing of amniotic fluid by the baby Individuals AT RISK for Hepatitis B: Healthcare workers o All who are in contact with body fluids of patients Blood recipients Hemodialyzing patients 49
Drug addicts Promiscuous individuals with multiple sex partners Incubation Period Six (6) weeks to six (6) months
Cerebrospinal Fluid Milk Urine Semen o In fact, all fluids Harbor the microorganism Mode of Transmission Percutaneous o Use of contaminated sharps and needles o Blood Transfusion Oral to oral Transmission o In saliva Sexual Transmission o Seminal fluid o Cervical fluid Vertical Transmission Swallowing of amniotic fluid by the baby Individuals AT RISK for Hepatitis D: Healthcare workers o All who are in contact with body fluids of patients Blood recipients Hemodialyzing patients Drug addicts Promiscuous individuals with multiple sex partners Incubation Period Three (3) weeks to twelve (12) weeks
HEPATITIS C Also called: o Post-transfusion Hepatitis Rationale: o Because people who develop this are those who have undergone blood transfusion Causative Agent Hepatitis C virus Important Concept! In Hepatitis C infected individuals Blood Harbors the microorganism Mode of Transmission Percutaneous Individuals AT RISK for Hepatitis C: Hemodialyzing patients Healthcare workers Drug addicts Blood Recipients Incubation Period Five (5) to twelve (12) weeks HEPATITIS D Also called Dormant Type of Hepatitis B Important Concepts! A person must have Hepatitis B before he could be infected with Hepatitis D Hepatitis D cannot multiply by itself It cannot bring about infection If Hepatitis B is present in the body, Delta virus activates Hepatitis B virus to help the Delta virus multiply Causative Agent Hepatitis D virus Delta virus Important Concept! In Hepatitis D infected individuals o Blood Harbors microorganism o Other body fluids Tears Saliva Sweat
HEPATITIS E Also called o Enteric Hepatitis Causative Agent Hepatitis E virus Important Concept! In individuals with Hepatitis E o The Feces Harbors the microorganism Mode of Transmission Fecal – Oral route Individuals AT RISK for Hepatitis E: Those living in unsanitary conditions Those who practice anal – oral sex
the
Incubation Period: Two (2) to six (6) weeks HEPATITIS G No synonyms 50
Causative Agent Hepatitis G virus Important Concept! In individuals with Hepatitis G o The Blood Harbors microorganism Mode of Transmission Percutaneous
Above three (3) manifestations are due to inability of the liver to deaminase proteins Anemia Paleness Pallor o The above three (3) manifestations are due to decreased life span of Red Blood Cells (RBC) o Normal live span of RBCs is one hundred twenty (120) days o In hepatitis patients, RBCs live for less than one hundred twenty (120) days End-product of RBC breakdown is bilirubin o Accumulation of bilirubin into the system leads to the 2 nd Stage – Icteric Stage o
the
Individuals AT RISK for Hepatitis G: Hemodialyzing patients Healthcare workers Drug addicts Blood Recipients Incubation Period Unknown IMPORTANT CONCEPTS!!! Similar Types or Partner Types Hepatitis A and Hepatitis E Hepatitis B and Hepatitis D Hepatitis C and Hepatitis G
2nd Stage – Icteric Stage Patient exhibits: Jaundice o Due to inability of the liver to eliminate normal amounts of bilirubin o Body compensates by eliminating bilirubin through sweat Pruritus o Due to accumulation of bile salts in the skin Tea-colored Urine or Brown-colored Urine o Due to excess bilirubin thrown out by the kidney in the urine Acholic Stool or Clay-colored Stool o Due to absence of bilirubin (conjugated bilirubin) that normally goes to the duodenum to color the stool Hepatomegaly o Enlargement of the liver o Due to an overworked liver Important Concept! o Viral infections are self-limiting If no complication arises, this would lead to the 3rd Stage – Post-Icteric Stage
Manifestations of Hepatitis Three (3) Stages 1st Stage – Pre-Icteric Stage This occurs before jaundice arises The patient experiences: 1. Fever o Due to infection 2. Right Upper Quadrant pain o Due to inflammation and infiltration of the liver 3. Fatigability 4. Weight Loss 5. Body Malaise o The three (3) manifestations above are due to the inability of the liver to convert glucose to glycogen o Body compensates by breaking down protein o End-product of protein breakdown would be amino acids o Amino acids are normally deaminated by the liver so that they could be eliminated 6. Anorexia 7. Nausea 8. Vomiting
3rd Stage – Post-Icteric Stage Jaundice disappears 51
1.5)
Signs and symptoms subside Energy level increases Patient is on the road to recovery Important Concept! o It takes three (3) to four (4) months for the liver to regenerate or recover o Physician usually advices rest for complete liver recovery or regeneration Most important Health Teaching: o Avoid alcohol for a period of one (1) year o Avoid over the counter drugs (OTCs) that are hepatotoxic for one (1) year o Consult physician prior to use of over the counter drugs.
LDH Lactate Dehydrogenase When identified, it indicates organ damage
liver
2. Serum Antigen-Antibody Test for Hepatitis 2.1) For Hepatitis A HAsAg Hepatitis A Surface Antigen Anti-HAV Presence of IgG Presence of IgM 2.2) For Hepatitis B HBsAg Hepatitis B Surface Antigen Anti-HBs 2.3) For Hepatitis E HBeAg Protein-independent Antigen Anti-HBe 2.4) For Hepatitis C HCsAg Hepatitis C Surface Antigen Anti-HCs Medical Management of Hepatitis No specific treatment Treatment is symptomatic as causative agent is a virus
Diagnostic Tests for Hepatitis 1. Liver Enzyme Tests Tests for extent of liver damage 1.1)
ALT Alanine Aminotransferase Formerly SGPT Serum Glutamic-Pyruvic Transaminase If increased, there is a liver problem enzyme to increase in the First presence of a liver problem 1.2) AST Aspartate Transaminase Formerly SGOT Glutamic-Oxaloacetic Serum Transaminase Increases only upon the onset of jaundice 1.3) ALP Alkaline Phosphatase Increase indicates: o Obstructive Jaundice Obstructive Hepatitis o o Obstruction in the Biliary Tract 1.4) GGT Gamma Glutamyl Transferase When increased o Patient is experiencing TOXIC HEPATITIS Due to toxic substances Alcohol Hepatotoxic agents
Most Common Drugs used in Hepatitis: Essentiale Jetipar Silymarine The above three (3) drugs are: o Hepatic protectors Composed of multivitamins, phospholipids and nutrients needed by the body so that the liver would not be overworked and be relaxed, and thus, recover Latest Trend in Pharmacological Management of Hepatitis Utilizes a combination of: 1) Lamivudine o Anti-viral drug o Dosage: Once daily for one year o Action: 52
o
Depends on the situation o If the patient is infected Provide moderate protein intake o If the patient is in the recovery stage Provide increased protein intake o If complications arise Provide decreased protein intake Key Concept! The most fatal form of hepatitis is HEPATITIS B! Even if patient recovers, after twenty (20) or thirty (30) years, the patient would develop cancer of the liver or cirrhosis of the liver
Inhibits multiplication of the virus
o
Cost:
Approximately Php200 / tablet
2) BRM o Biologic Response Modifiers o An immunomodulating drug o Interferons Injectable form of BRM Normal substance produced by the body when virus enters the human cell o Dosage: Two (2) to three (3) times a week for six (6) months o Action: Kills the virus o Cost: Approximately Php85,000!!! Nursing Care for Hepatitis Two (2) Important Aspects
Preventive Measures for Hepatitis 1. Immunization Hepatitis B vaccine Number of Doses: o Three (3) Interval between doses: Four (4) weeks o When given: o 1st Dose – Six (6) weeks from birth o 2nd Dose – Ten (10) weeks from birth o 3rd Dose – Fourteen (14) weeks from birth Dosage: o 0.5 cc Route: o Intramuscular Site: o Vastus lateralis Important Concepts!!! o Inform the mother that there would be pain and soreness on the injection site o A slight elevation on liver enzyme tests is a NORMAL REACTION to the vaccine 2. Avoid the different modes of transmission For Hepatitis B, C, and D o Blood-borne diseases
1. Provide Complete Bed Rest (CBR) To promote liver regeneration and recovery there is decreased When rested, metabolism Less metabolism leads to decreased liver load Liver relaxes and liver recovers 2. Diet Low fat diet Because there is not enough o bile released or produced by the liver Increased Carbohydrate Intake o To spare protein metabolism o To decrease amino acids o Accumulation of protein breakdown products like ammonia would lead to hepatic encephalopathy
Butterball Diet o Produces energy o These are hard candies o Chocolates are contraindicated They contain fat Protein Intake 53
There is a Needle-exchange Program in the United States and in Australia o Every 6:00 PM a healthcare worker is given a knapsack with needles and sharps o He then proceed to areas of distribution – alleys o Exchanges new syringes with old syringes used by drug addicts.
COMMUNICABLE DISEASES OF THE GENITOURINARY SYSTEM – SEXUALLY TRANSMITTED DISEASES
Prostatitis o Abscess formation on the prostate gland Purulent Discharges o Mostly abundant in the morning If gonorrhea is persistent, a scar develops on the EPIDIDYMIS o Scar obstructs the flow of the sperm cells Sterility o Due to obstruction of sperm cell flow
In females: Burning sensation upon urination if urinary meatus is involved o Urinary meatus is seldom involved in gonorrhea. o Cervix is usually the one that is affected or absence of purulent Presence discharges Important Concept! o If there is no burning pain and no purulent discharge, the patient may not know that she is infected o Presence of abscess formation on the Bartholin’s Gland or the Skeene’s Gland o When this abscess goes up, it gives rise to ENDOCERVICITIS or ENDOMETRITIS Hypogastric Pain o Due to presence of endocervicitis or endometritis Important Concept! o Either of Endocervicitis or Endometritis could give rise to Pelvic Inflammatory Disease o Pelvic Inflammatory Disease A systemic disease characterized by: Fever Severe abdominal pain Nausea and Vomiting This is secondary to gonococcal infections Sterility and Ectopic Pregnancy
Bacterial Gonorrhea Syphilis Viral HIV Infection AIDS GONORRHEA Also called Clap resembles hands Microorganism clapping together Strain Gleet Jack GC Morning Drop Causative Agent Neisseria gonorrhea Mode of Transmission Sexual contact Important Concepts! o Most of the time, MALES are infected Urethra are affected leading to urethritis Females can also be infected o Cervix is affected o Signs and symptoms develop at a later stage Manifestations of Gonorrhea
• •
In males: Burning pain, burning sensation upon urination o Due to redness and edema of urinary meatus brought about by acidic urine
•
•
54
If gonorrhea persists, it causes a narrowing of the Fallopian Tube Gonococcal Septicemia o Occurs when gonorrhea is already systemic Signs and symptoms would o include: Presence of Gonococcal Rashes Papular Elevated Rashes Pustular With pus May be necrotic gonococcal rashes Polyarthritis develops Tenosynovitis o Tendons and synovium are affected Important Concept! o Effect of disease to child of mother with gonorrhea: Opthalmic neonatorum o Management: Give CREEDE’S PROPHYLAXIS to prevent blindness in the newborn Diagnostic Tests for Gonorrhea
If given per I.V., it will KILL THE PATIENT!!!! It is oil based It forms into an EMBOLUS that would kill the patient o When given per I.M. Use big gauge needle Gauge 16 – 18 This drug easily coagulates This drug easily clots Therefore, administer this drug QUICKLY Dilute with one (1) cc of LIDOCAINE One cubic centiliter (1cc) of Lidocaine plus four (4) cubic centiliters of Plain Normal Saline Solution is used to provide less pain o Rationale: Due to the incorporation of an anesthetic in the form of Lidocaine Key Concept! o If the patient is Pregnant Sensitive to Penicillin o SPECTINOMYCIN Administer instead!!! Key Concept! o If patient with gonorrhea has chlamydial infection or vice versa (Gonorrhea and Chlamydia are TWIN SISTERS) Do not give Penicillin Do not give Spectinomycin DOXYCYCLINE o Administer instead!!!
o
•
•
1. Culture and Sensitivity Collect urethral discharges Done by scraping mucosa of the urethra 2. Papanicolau’s Smear or Vaginal Smear For females
Medical Management of Gonorrhea 1. Anti-biotics Drug of Choice o Penicillin o Benzathine Pen G (Penadur) o Given also to Rheumatic Heart Disease patients Important Concepts!!! o Penicillin G is NEVER GIVEN PER I.V. o For I.M. use only o Rationale:
Nursing Care for Patients with Gonorrhea Gonorrhea patients are not confined They are treated on an outpatient basis 1. Psychological Aspect of Care STD patients have low self-esteem 2. Health Teaching 55
Education
and
Patient
To prevent recurrence of infection
Tongue Under the breasts On fingers o If without treatment, chancre disappears, it will signal the start of the Secondary Stage Secondary Stage of Syphilis Patient exhibits: Flu-like symptoms o Sore throat o Headache o Fever Several forms of dermatitis o Rashes (Kulugo) All over the body o Presence of dry, hard wart-like lesions Condylomalata o Infectious lesions that are fused together o Found under the breast and on the genitals o Highly infectious lesions Key Concept! o Secondary Stage is highly infectious o Also called Infectious Stage Changes in hair growth o Patchy Alopecia all over o Patient has MOTH-EATEN APPEARANCE Affects growth of pubic hair o Thinning of pubic hair o Management: Patient uses aloe vera Patient uses Mane and Tail Key Concept!!! o Before the Tertiary Stage of Syphilis occurs, the patient becomes ASYMPTOMATIC o This may be called the LATENT PHASE A transition period of one (1) to two (2) years. Tertiary Stage of Syphilis Patient exhibits: Gummatous Lesions or Gumma o Characteristic lesion o Lesions that are found on deeper tissues and organs of the body
Preventive Measures Safe Sex According to the Center for Disease Control, “safe sex” means: o No sex o Mutual monogamous relationship o Mutual masturbation without direct contact Holding of body parts but no sex Important Concepts! o Condom is not an example of safe sex o Condom use is not 100% guaranteed in preventing infection o Best way to prevent spread of infection is through BEHAVIOR MODIFICATION o Also called LOW-RISK Behavior SYPHILIS Also called: o Pox o Lues Sy o o Bad Blood Disease Causative Agent Treponema pallidum Mode of Transmission Sexual Contact May be transmitted vertically o May pass placental barrier after sixteenth (16th) week of pregnancy Rarely transmitted thorough Blood Transfusion Manifestations of Syphilis Three (3) Stages Primary Stage of Syphilis Patient exhibits: Chancre o Characteristic lesion o Painless popular lesions that heal spontaneously without treatment o Found on the: Genitals Face Lips 56
Some are in the form of infiltrating tumors Other organs of the body are also affected o Most commonly affected is the HEART This gives rise to o CARDIOVASCULAR SYPHILIS Neurosyphilis o Central Nervous System affectation o Neurologic symptoms are present Lack of Balance Dementia o
o
o
If I.M. preparation is given via I.V. Patient dies due to dysrhythmias If I.V. preparation is given via I.M. Viscous medication would give rise to pain upon administration
Nursing Management in Syphilis Same as in gonorrhea Preventive Management of Syphilis Same as in gonorrhea Important Concepts!!! of syphilis to child whose Effect mother developed syphilis during pregnancy: o Still Birth (baby dies) o Syphilitic Baby Placenta is bigger than the baby Baby resembles the appearance of an old man Baby has linear scars at angles of the mouth Baby has persistent vesicular eruptions or blisters Baby has nasal discharges Mother may NOT give birth to a child with syphilis but may give birth to a child with LATE SYPHILIS o Two (2) years after birth, the child will manifest: Hutchinson’s Teeth Saw-like teeth Anterior Bowing of the Tibia Fractured Tibia Backward Tibial growth Saddle nose with high palate Deafness Persistence of dactylitis o If child with Late Syphilis is not given prophylaxis upon adolescence Child develops neurosyphilis
Diagnostic Tests for Syphilis 1. Culture and Sensitivity Done by mucosal scraping 2. Dark Field Microscopy 3. Blood Examination 3.1) FTA-ABS Fluorescent Treponema Antibody Absorption Test o This is the confirmatory test for syphilis 3.2) VDRL Venereal Disease Research Laboratory This is not a definitive test o 3.3) RPR Reactive Plasma Reagent o Non-definitive test for syphilis Medical Management of Syphilis 1. Anti-biotics Drug of Choice o Penicillin If patient is sensitive to Penicillin o Administer a Cephalosporin instead o Choice of Cephalosporin Ceptriaxone or Rocephin Given per I.M. or per I.V. o Different diluents are used: o When given I.V. Diluent used is Sterile Water o When given I.M. Diluent used is Xylocaine Important Concepts!!! o Do NOT INTERCHANGE diluents!
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Child will eventually die Mother may NOT give birth to a child with syphilis o Child may be born NORMAL o Child may be ALIVE and NORMAL o But wait for two (2) years to really declare that child is normal
Therefore, AIDS cannot be acquired through the swimming pool o By Ordinary House Bleaching Soap with Sodium Hypochlorite Zonrox Chlorox Purex Domex Proportion of bleaching soap to water is 1:10 Important Concepts! o If virus leaves the body of an individual infected with AIDS (i.e. through the semen), the virus will survive for only four (4) hours o If it does not penetrate another person, the virus WILL DIE o But if the virus goes out with blood, the VIRUS WILL REMAIN ALIVE, as long as the BLOOD IS FRESH!!! o Once a person dies with AIDS, the virus remains in the body of the individual, as long as, the body is HUMID o Therefore, the body of an AIDS victim should be cremated within twenty-four hours after death or sealed in a metal coffin, also within twenty-four (24) hours from death. o The body of an AIDS victim COULD NOT BE EMBALMED The virus will INFECT THE EMBALMERS
Important Concepts!!! If you are pregnant, do not be infected with syphilis Do not get infected with syphilis, particularly in the third (3 rd) trimester of pregnancy. The nearer you give birth to a child, the greater is the chance that the child would develop congenital anomalies
ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) Important Concept!!! Immune Deficiency Acquired Syndrome (AIDS) is DIFFERENT from HIV Infection HIV Infection Means that you are infected with the virus Initial stage of AIDS AIDS Means that you are infected You manifest a group of signs and symptoms With decreased or weakened immune system This is the end-stage of HIV infection Key Concepts! All patients with HIV infection will develop into AIDS All AIDS patients have passed through the HIV stage Causative Agent Human Immuno-Deficiency Virus A Retrovirus A very fragile virus Can easily be destroyed by: o Seventy percent (70%) alcohol o A temperature of fifty-six degrees Celsius (56°C) o Chlorine
Modes of Transmission Blood Transfusion per Single Exposure Single Blood Transfusion o Provides 90% chance of infection Sexual Contact Pandemically, the number one mode of transmission o Single exposure gives 0.1% to 1.0% chance of infection o However, due to repeated sexual encounters, chance of infection increases Contaminated Sharps and Needles 58
HIV (Retrovirus) Has special affinity for T cells ▼▼▼ Retrovirus is NOT DETECTED by the Macrophages ▼▼▼ Macrophages will NOT BE ABLE TO ALERT the T cells ▼▼▼ Retrovirus ENTERS the T cell ▼▼▼ Retrovirus releases the enzyme REVERSE TRANSCRIPTASE This resembles the genetic make-up of the T cell ▼▼▼ T cell does not destroy the virus ▼▼▼ T cell BECOMES a PRO-VIRUS ▼▼▼ Virus multiplies within the T cell ▼▼▼ T cell is DAMAGED ▼▼▼ Virus will retrovert before leaving the T cell ▼▼▼ Virus leaves T cell ▼▼▼ Virus attacks another T cell ▼▼▼ Net effect: No T cells will be present to stimulate the B cells ▼▼▼ No B cell stimulation ▼▼▼ No antibody production ▼▼▼ No antigen-antibody reaction occurs ▼▼▼ Person is infected but remains asymptomatic
Single exposure gives 0.1% to 0.5% chance of infection Vertical Transmission From the infected mother to the unborn fetus o Gives 30% chance of infection Important Concepts!!! If a child is born to a mother who is HIV positive, the child would ALWAYS have a POSITIVE RESULT for HIV TESTING o HIV testing identifies the presence of antibodies in the blood Child possesses maternal antibodies Therefore, child is positive for o HIV but may this may not mean the child is infected Child is given up to eighteen (18) months for HIV testing o After eighteen (18) months, child must be negative for HIV testing o If child is still positive for HIV testing after eighteen (18) months, then the child is REALLY INFECTED!!! NORMAL IMMUNE RESPONSE
Microorganism ▼▼▼ Detected by the Macrophages ▼▼▼ Macrophages will alert T cells ▼▼▼ Alerted T cells reproduce and multiply ▼▼▼ T cells stimulate the B cells ▼▼▼ B cells reproduce and multiply ▼▼▼ B cells release the antibody ▼▼▼ Antibody produced attacks the invading microorganism ▼▼▼ Antigen-Antibody reaction occurs ▼▼▼ Manifestation of Disease will be present
Important Concept! In the course of the HIV infection, the macrophages CANNOT IDENTIFY the HIV As the body takes more time to develop antibodies to the HIV, the person BECOMES INFECTED but REMAINS ASYMPTOMATIC A WELL-WORRIED INDIVIDUAL ▼▼▼ ▼▼▼ ▼▼▼
Important Concept! In HIV Infection, there is an alteration in the NORMAL Immune Response 59
Major Symptoms Fever: One (1) month and above in duration and is recurrent Diarrhea: One (1) month and above Ten percent (10%) weight loss o Staunted growth in children Minor Symptoms generalized Persistent lymphadenopathy Generalized pruritic dermatitis Persistent cough: One (1) month and above Oropharyngeal Candidiasis Recurrent Herpes Zoster Disseminated Herpes Progressive Simplex Continually multiplying and continually growing mouth sores
Infected with HIV but is ASYMPTOMATIC ▼▼▼ ▼▼▼ ▼▼▼ After six (6) weeks to six (6) ▼▼▼ months (called the WINDOW ▼▼▼ PERIOD or the time interval ▼▼▼ between the infection of the ▼▼▼ individual to the production of ▼▼▼ the antibodies), where the ▼▼▼ body produces antibodies ▼▼▼ ▼▼▼ ▼▼▼ ▼▼▼ ( + ) for HIV infection With AID Related Complex (ARC) Symptoms ▼▼▼ ▼▼▼ ▼▼▼ Months to years ▼▼▼ ▼▼▼ ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) ▼▼▼ ▼▼▼ ▼▼▼ Months to years ▼▼▼ ▼▼▼ DEATH occurs
Important Concepts! False-Negative Result for AIDS o No antibodies are identified but patient is already infected o This occurs during the WINDOW PERIOD The person who undergoes HIV testing undergoes counseling o This person should not engage in any of the modes of transmission of AIDS before the window period ends The ACTIVE PARTNER o Considered the GIVER Has less chances of becoming o infected The PASSIVE PARTNER o Considered the RECEIVER o Has greater chances of being infected AGAIN, DO NOT ENGAGE in any of the modes of transmission of AIDS DURING the WINDOW PERIOD!!! Important Concepts!!! If an adult manifests the following: o Two (2) major symptoms o One (1) minor symptom o Then, that adult is AIDS BONAFIDE If a child manifests the following: o Two (2) major symptoms o Two (2) minor symptoms
Important Concepts! AIDS Related Complex Symptoms include the following: Fever with night sweats without a cause o All laboratory works are negative Enlargement of lymph nodes without a cause o All laboratory works are negative Fatigability Weight Loss Altered Sleeping Patterns Temporary Memory Loss Altered Gait Manifestations of AIDS For adults o Two (2) major o One (1) minor For Children o Two (2) major o Two (2) minor
symptoms symptom symptoms symptoms 60
Then, that child is AIDS BONAFIDE Key Concepts! a person has AIDS, all When microorganisms entering his body gives rise to infections are called OPPORTUNISTIC These INFECTIONS In the Philippines, the Number One Opportunistic Infection is TUBERCULOSIS Important Concepts!!! Cancers Associated with AIDS o Caposi Sarcoma A malignancy of blood vessel wall or the vascular endothelium Manifested through the skin With pink or purple, painless spots on the skin Gives rise to a “LEOPARD-LOOK” o Non-Hodgkin’s Disease Cancer of the lymph nodes Diagnostic Tests for AIDS
Monitors replicating activity of the virus o Negative ( - ) Viral Load Means virus is not actively multiplying but is still present 3.2) CD4 and T cell Count o o Establishes STAGE OF INFECTION, whether it is HIV or AIDS Indicates HIV infection If greater than or equal to 200 Indicates AIDS If less than 200 Medical Management for AIDS Symptomatic management as virus is the causative agent Trend in Pharmacologic Latest Management of AIDS o COCKTAIL DRUGS Patient must take medication composed of at least twenty-one (21) tablets per day Patient spends approximately Php1,000 per day on drugs Prevents multiplication of the virus but DOES NOT KILL THE VIRUS 1.Nucleoside Reverse Transcriptase Inhibitors NRTIs o AZT Azidothymidine Retrovir Zidovudine o ddc Dideoxycitidine Zalcitadine o ddI Dideoxyinosine Didanosine Tastes sour Give together with fruit juice o Lamivudine o Stavudine
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1. ELISA Enzyme-Linked Immunosorbent Assay o This is only a SCREENING TEST for AIDS 2. PCR Test Polymerase Chain Reaction Test o Likewise, a SCREENING TEST for AIDS o Relatively expensive o Costs approximately Php5,000 to Php7,000 per test o Results are known within two (2) to three (3) hours Important Concept! If a person o Has been twice positive for ELISA and; o Has been positive once for PCR Then confirm the results by doing the next test… 3. Western Blot If a person is diagnosed with HIV Tests continue Monitor the following: o 3.1) Viral Load
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2.Non-nucleoside Reverse Transcriptase Inhibitors Non-NRTIs 61
