COMMUNICABLE DISEASES  Diseases caused by pathogenic microorganisms, which can be transmitted from an infected person to a susceptible person by direct,

indirect means or through a break in skin integrity Communicable Diseases are transmitted through: 1. Direct Mode of Transmission  A person to person transmission  Most common is through Droplet transmission  Examples: o Kissing o Sexual Contact  Happens in humans 2. Indirect Mode of Transmission  From a source of transmission to a new host with intermediary object  A bridge connects you to an infected person  Bridges or intermediate objects  Examples: o Vehicle-borne Transmission  Non-living things  Articles used by patient like catheter, tubings, linens  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  There is no limitation to the distance traveled by microorganism  Different from Droplet transmission  Microorganism remains on surface  Travel is limited to a maximum distance of three (3) feet. Concept:  All these modes are classified under Horizontal Transmission Horizontal Transmission  Manner of transfer of microorganisms is in a horizontal position Vertical Transmission  Manner in which microorganisms are transferred is in a vertical manner from up going down  Example: o Infected mother to newborn child 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 not be transferred from one person to another Contagious Diseases  Diseases that can easily be transmitted Concepts:  All communicable diseases are infectious but not contagious  Because there is the presence of a living microorganism  Because not all of the microorganisms can be easily transmitted  All contagious diseases are infectious  All contagious diseases are 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  If resistance is low, susceptible person is prone to infection Types of Hosts: 1.1) Patient  A person infected manifesting signs and symptoms 1.2) Carrier  Individual who harbors microorganisms but shows no signs and symptoms 1.3) Suspect  Individual whose medical history and symptoms suggests that he may be developing a specific infection  Signs and symptoms are suggestive 1.4) Contact  Individuals who come in close association or in contact or exposed to infected person

Concepts:  The PATIENT is the least source of infection  The PATIENT has the least chance to spread microorganisms o Because he manifests signs and symptoms of the disease, he is isolated o Precautionary measures are now taken  The CARRIER has the highest potential to spread infection o Because he does not manifest signs and symptoms of the disease o However, he has the microorganisms 2. AGENT  Microorganisms  They have the highest population among all living things  Not all are susceptible to microorganisms  Not all microorganisms are virulent Concepts: Virulence  Strength and power of microorganisms to cause infection Pathogenicity of microorganisms  Capacity of microorganisms to cause infection Two (2) most common microorganisms causing infections  Bacteria  Viruses Bacteria  Can multiply in both living and non-living things  Cannot pass through filters in the body because they are big  Therefore, it is okay to have bacterial infection even during pregnancy, except for Treponema pallidum, which passes through the placental barrier after the 16th week of pregnancy.  Syphilis is not fatal in the first trimester  Syphilis is fatal in the third trimester  Anti-bacterial medications give only 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  It gives rise to self-limiting diseases  Viral infections have own time frame  Example: o Colds last for 2-3 days with watery secretions as symptoms

After this, complications would be the one present with yellowish or mucoid discharges probably indicative of sinusitis o Influenza is present for one week  After one week, pneumonia sets in.  Medical management for viral infections: o Treated symptomatically not by anti-viral agents o Antibiotics may be used to treat secondary bacterial infections o Purpose is to increase body resistance  3. ENVIRONMENT  Must be conducive and favorable to growth of microorganisms  Example: o Clostridium tetani will not cause infection in the presence of oxygen because it is an anaerobic microorganism Concept: There must be an interplay between 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  A place where microorganisms can live and multiply  Examples: o T. pallidums reservoir is the human genitalia o Measles virus reservoir is the nasopharynx o Salmonella typhosas reservoir are the Peyers patches of the small intestines 3. Portal of Exit  From the reservoir, microorganisms look for a way out  This pertains to the individuals body system  Examples: o T. pallidums portal of exit is the genitourinary system o Measles virus portal of exit is the respiratory system o Salmonella typhosas portal of exit is the gastrointestinal tract 4. Mode of Transmission

 When outside of the host, this pertains to the microorganisms means of transportation  Examples: o T. pallidums mode of transmission is sexual contact o Measles virus mode of transmission is airborne nuclei o Salmonella typhosas mode of transmission is fecal-oral ingestion 5. Portal of Entry  A microorganisms way in to the new host  Also corresponds to the individuals body system  Examples: o T. pallidums portal of entry is the genitourinary system o Measles virus portal of entry is the respiratory system o Salmonella typhosas portal of entry is the gastrointestinal tract 6. Susceptible Host Concept:  Objective or goal is to limit, prevent or control spread of communicable diseases by breaking the chain 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 o It is not the RESERVOIR (i.e. you 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 cannot remove the genitals 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 fecal-oral 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 1. Natural Immunity  Inherent in an individuals 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 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  An actual participation of the individuals body tissues and fluid in PRODUCING immunity  You produce the antibodies yourself when microorganisms are 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 o Measles attack wherein antibodies are produced by nature  Sub-clinical immunity o Developed due to constant exposure to certain infection o Body produces antibodies non-intentionally by nature that provides immunity 2.1.2) Artificially Acquired Active Immunity  Body produces antibodies because it was intentionally done  Examples: o Vaccines  Attenuated (weakened) microorganisms o Toxoids  Attenuated toxins (poisonous substances) produced by microorganisms Concepts!  When administering vaccines or 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

2.2) Passive Acquired Immunity  Immunity is developed due to 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) Types of Passive Immunity 2.2.1) Naturally Acquired Passive Immunity  Done by nature  Antibodies given or obtained by 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  Administration of substances containing antibodies in an intentional manner  Examples: o Anti-toxins o Anti-serum o 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

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  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  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  Dogs must initially be registered before this vaccine could be administered 1.3) Environmental Sanitation  Objective: o No proliferation of arthropods, rodents (both of which are good vectors) Presidential Decree 856 Sanitation Code  Also includes submission of sex 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 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 of Food Handlers  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

 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  Intended to protect the 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 Center for Disease Controls two (2) Revised Isolation Precautions 1) Standard Precaution  Best strategy to prevent nosocomial infection  Slowly taking place of Universal Precaution  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 For Surgical Asepsis:

2. CONTROL ASPECT  Done when signs and symptoms are already present

 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 3. Avoidance of Needle Stick or Sharps Injury  Do not recap, bend or break needles  There must be puncture-resistant sharps collector 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  For diarrheal diseases, typhoid, cholera, hepatitis, skin diseases like ringworm, scabies and pediculosis 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 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 2. Disinfestation  Killing of undesirable small animal forms such as arthropods, rodents, insects by physical or chemical means 3. Fumigation  Use of gaseous agents to kill arthropods, rodents and insects. 4. Medical Asepsis  Hand washing  Gloving  Gowning  Masking  Placarding o Placing NO SMOKING sign when there is oxygen inhalation in progress. COMMUNICABLE DISEASES OF THE CENTRAL NERVOUS SYSTEM Bacterial infections  Tetanus  Meningitis Viral Infections  Encephalitis  Poliomyelitis  Rabies TETANUS  Also called LOCKJAW  With painful muscular spasms  Ten times more painful than leg cramps  Clostridium tetani o Causative agent of Tetanus o Anaerobic microorganism o Abundant in soil, dust, clothing

o o o

It exists in the form of a SPORE outside the human body That is why it survives outside the human body even in the presence of oxygen Sterilization is needed to kill the microorganism

In the wound, there would be an inflammatory response:  Rubor - rednes  Calor - heat  Tumor - swelling  Dolor - pain  Functiolaesa loss of function 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 o Therefore, it affects the closing of the mouth muscle o This is called LOCKJAW or PRISMUS  Facial muscle is affected o Gives rise to risus sardonicus 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 o In the vernacular, it is called LIAD  Respiratory muscles are affected o Results to difficulty of breathing, dyspnea and chest heaviness  Genitourinary tract muscles are affected o Results into urinary retention o Intervention would involve catheterization  Gastrointestinal muscles are affected o 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 Concept!  Thus, almost all of the muscles are rigid and stiff in Tetanus! Diagnostics for Tetanus:

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) 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 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 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  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.

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  If there is a fresh wound, 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 of Medical Management 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 o If (+) for skin testing, DO NOT GIVE the drug.  Resort to human serum tetanus immunoglobulin 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 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. 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. o 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  For urinary retention, do catheterization  For constipation, administer laxatives as ordered Nursing Management in tetanus  Muscle spasms are the first concern Concept:  Stimuli trigger spasms. Types of Stimuli: 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  Examples are touching, turning, 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  Practice minimal handling of the patient o Avoid unnecessary disturbance of the patient  Practice Cluster Care

  

Do all nursing care activities in one setting Do other nursing care activities with vital signs taking 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 o 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 o

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. 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!!!  Attack of tetanus does not give permanent immunity Vaccine Given: 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

IMPORTANT CONCEPTS!!!  Expect fever to set in after 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 o This indicates that child has 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. DPT Immunization for Pregnant Individuals  Dose: 0.5 ml  Route: Intramuscular  Number of Doses given: o 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 For High-Risk Individual  1st Dose given:

o 03-05-2005  2nd Dose given: o 04-05-2005  3rd Dose given: o 10-05-2005 (six months after the LAST dose)  4th Dose given: o 10-05-2006 (After one (1) year from the LAST dose)  5th Dose given: o 10-05-2007 (After one (1) year from the LAST dose) 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  Effect of Tetanus Toxoid 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 Key Concept!!!  Avoid Wounds MENINGITIS  Inflammation of the meninges (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 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 infection for AIDS

opportunistic

 Bacterial o Tubercle Bacilli  TB meningitis  Staphylococcal meningitis o Secondary to skin infection  Haemophilus influenzae bacilli o Common cause of meningitis in 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) o Causative agent is Neisseria meningitides 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  Respiratory system via the nasopharynx Pathophysiology of Meningitis  From the nasopharynx, the microorganism goes to the bloodstream  Once in the bloodstream, the 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

10

 

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 

If pain is present, the patient is said to be positive (+) for Kernigs Sign or difficulty of extending the leg  Positive for Brudzinskis Sign o Place the patient in supine position o Flex the neck o If there is no reaction, the patient is said to be negative (-) for Brudzinskis 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 Brudzinskis Sign  Diagnostic Tests for Meningitis 1. Lumbar Puncture  Cerebrospinal Fluid (CSF) is the specimen used o Assess for the color of the CSF  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 ImmunoElectrophoresis (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 o 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

Pathophysiology of Meningococcemia  Portal of entry of Neisseria 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 (pantalpantal) purpuric lesions o They are purplish in color o Usually found on the wrist and 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 Kernigs Sign  Place patient in supine position  Flex both knees toward the abdomen  Then ask the patient to extend the legs

to the bloodstream
Medical Management of Meningitis  If bacterial

11

Give anti-bacterial agent in the form of antibiotics

 If viral o Symptomatic  If fungal o Give Amphotericin B  If with inflammation o Give corticosteroids in the form 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  Nursing Care for I.V. administration of Dilantin y Sandwich Dilantin with NSS y NSS Dilantin NSS  Rationale: y Dilantin would crystallize o Per Orem  Nursing Care for P.O. administration of Dilantin y Do frequent oral care y Do gum massage o Rationale:  Dilantin causes gingival hyperplasia or overgrowth of the gums 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-Fowlers position (30 incline) o Provide comfort measures o Massage the forehead o Do petrissage with circular action 3. Potential for injury related to altered level of consciousness  Never leave the patient alone  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 Preventive Measures 1.Proper disposal of nasopharyngeal secretions  Burning  Burying  Proper procedure for disposal of 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  Children have less chance of spreading infection because they swallow nasopharyngeal secretions.  This is contraindicated, however, for tuberculosis patients

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 Thus, for TB patients, they have to spit out nasopharygeal secretions  Swallowing is allowable for other respiratory infections 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.  Wear mask when you enter the patients room 3. Vaccine  Hib vaccine for Haemophilus influenza 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 o Culex tarsalis  Ticks of horse  Migratory birds Secondary cause  Post racene encephalitis Toxic  Metal poisoning o Lead poisoning o Mercury poisoning 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 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 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 temporary immunity, due to causation by various viruses  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 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 Important Concepts!  When Brunhilde infects you, Leon or Lansing will no longer affect you!  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  Fecal-Oral Route o In late stage of transmission, virus is found at the mouth

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 Portal of Entry  Gastrointestinal Tract Pathophysiology  Legio debilitans goes to the 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 Peyers patches and causes: o Abdominal pain o Anorexia o Nausea and Vomiting o Diarrhea or Constipation 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 Cervical Lymph Nodes Peyers Patches Mesenteric Lymph Nodes

It is a narcotic analgesic that would cause respiratory depression

 Once in the CNS, the microorganism will also cause: o Stiffness of the hamstring o Patient will be positive for HOYNES Sign and exhibit a HEAD DROP o To check for Hoynes 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 Hoynes 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 Central Nervous System Paralysis Concept!  From the CNS, the patient will experience paralysis.  This leads to the third (3rd) stage of the disease 3rd Stage: Paralytic Stage  Presence of paralysis  Characteristics of Paralysis: o Flaccid  Soft  Flabby  Limp Important Concept!  Flaccid Paralysis is PATHOGNOMONIC SIGN of Poliomyelitis Three (3) Types of Paralysis 1. Bulbar Type  Cranial nerves are affected  9Th cranial nerve (Glossopharyngeal Nerve) and 10th 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

BLOODSTREAM Central Nervous System 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  Do not do massage  No positioning will relieve patient o Instead, what would relieve the patient would be:  Application of warm packs  Analgesics o Never administer Morphine

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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 1. Lumbar Puncture  Laboratory results would reveal: o Increased White Blood Cell levels o Increased Protein levels 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  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  Place patient in a MECHANICAL 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

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  3rd Dose at fourteen (14) weeks old o Important Concepts!!!  Do not feed child for thirty (30) minutes after administration of OPV o Rationale:  For better absorption o If child vomits, REPEAT!!! o 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  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:

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Because stool of child may contain the virus if OPV is given

2. Avoid mode of transmission  Proper disposal of nasopharyngeal secretions  Cover mouth when coughing  Do not put anything through the mouth 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 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 Nerves CNS Pathologic Lesions (negri bodies) Efferent Nerves Salivary Gland of Rabid Animal

 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 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 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) Stage 1 Invasive Stage  Numbness on the site of the bite  Itchiness on the site of the bite  Flu-like symptoms o Fever o Headache o Sore throat  Marked Insomnia  Restless  Irritable  Apprehensive  Slight photosensitivity

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 Important Concept!  Therefore, you need not be bitten

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 Vague symptoms 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 Stage 2 Excitement Stage  Acrophobia o Fear of Air  Hydrophobia o Fear of Water Important Concept!  Air and Water both cause 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 o Club walls 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  Patients spasms will stop  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. Diagnostic Tests Done Before Patient Manifests Signs and Symptoms 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 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 y Submit yourself for treatment as soon as possible y This is due to the proximity of the bite to the brain o Velocity of Virus  Three millimeters per hour (3mm/hr) o Extent of Bite  Submit yourself for treatment at once if: y You have multiple bites y You have a deep bite o Reason for the Bite  If bite is provoked  Example: y You stepped on the dogs tail y Do not worry  If unprovoked  Example: y There is no reason y Then, WORRY, because IT IS A RABID DOG!!! Medical Management Post-Exposure Prophylaxis Vaccines 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  Purified Duck Embryo Virus

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o o o

PDEV Lyssavac 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 o Deltoid o Vastus lateralis Important Concepts!!! If active form of vaccine If via I.M.  Schedule is: Dose Day Example Dosage Remarks 1st 00 03/05/ 2 vials 1 cc on 2005 each site; One on the left and one on the right 2nd 07 3/12/ 1 vial One site 2005 only rd 3 21 3/26/ 1 vial One site 2005 only Important Concepts!!!  Counting is ALWAYS BASED on the FIRST DOSE!!!  You can afford not to continue vaccine if dog does not die after ten (10) days  However, continuance is encouraged 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  Avail of complete doses plus a BOOSTER DOSE o Booster Dose  Given at DAY 91  In the tabulated example y Schedule would be at 6/05/2005 y Dosage is one vial

If via I.D.  Schedule is: Dose Day Example 1st 00 03/05/ 2005

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

Dosage 0.1 cc if Verorab or 0.2 cc if Lyssavac Or Rabipur 0.1 cc if Verorab or 0.2 cc if Lyssavac Or Rabipur 0.1 cc if Verorab or 0.2 cc if Lyssavac Or Rabipur 0.1 cc if Verorab or 0.2 cc if Lyssavac Or Rabipur 0.1 cc if Verorab or 0.2 cc if Lyssavac Or Rabipur

Remarks Given on each site: Right 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

Important Concepts!!!  Verorab o Once reconstituted is only potent for eight (8) hours  Antibodies are produced in about seven (7) days  Therefore, also give passive form of vaccine. Passive Forms Temporary antibodies Animal Serum  Equine Rabies Immunoglobulin (ERIG) o Anti-rabies serum o HyperRab o FaviRab Important Concepts!  Do skin test first o If negative for skin test, give drug

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o o o

Dosage is based on body weight and is provided in direct proportion  0.2 cc / kg body weight is the standard  Example: y A 50 kg person would receive 10 ml of ERIG y Cost is approximately Php1,800 / 5.0 cc If positive for skin test, give HRIG or Human Rabies Immunolobulin  Imogam  Rabuman  0.133 cc / kg body weight is the standard dose  Example: y A 50 kg person would receive 6.65 cc of HRIG  Cost is approximately Php4,500 / 2.0 cc This is given as a single dose within seven (7) days from the date of the bite After seven days, patient already has antibodies Computed Dosage is divided in two  Half is given Intramuscular  On the ventrogluteal muscle or at the side of the buttocks Other half is...  Infiltrated around site of bite using four distinct points or  Given inside the wound of the patient This is prophylactic and is not considered as a treatment 

Nursing Care  Place patient in a dim and quiet environment  Keep patient away from sub-utility room  Restrain the patient before he exhibits maniacal behavior  Wear all Personal Protective Equipment when you enter the room because patient continues to spit Preventive Measures  Be a responsible pet owner o Have pets immunized  Wash wound with soap, water and antiseptic  Then observe the dog Important Concept!!!  Virus rabies is destroyed by 60C heat for thirty-five (35) seconds  Therefore, you will not acquire rabies from eating dog meat

COMMUNICABLE DISEASES OF THE CIRCULATORY SYSTEM DENGUE HEMORRHAGIC FEVER Important Concept!  Dengue Fever is different from 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  Type 2 Chikungunya  Type 3 West Nile  Type 4 Flavivirus o Brought epidemics in several areas in the Philippines Mode of Transmission  Mosquito Bite  Biological Transmitters o Aedes aegypti o Aedes albopectus  Mechanical Transmitter o Culex fatigans Biological Transmitter  After this mosquito has bitten an 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  After this mosquito bites an infected 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  Breeds on clear, stagnant water usually in urban area o Old tires o Flower vases o Plant cans  In the Philippines, any area is a dengue risk area  Other information: o When it lands on a surface, body of mosquito is on a PARALLEL POSITION and two (2) legs are raised o It has white stripes on legs

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It has a gray-millennium color

Four Classifications of Dengue Hemorrhagic Fever DHF Grade 1  Increased grade fever (lasts 3 5 days) o Even if antipyretics are given, fever will persist o Fever will come down but the patient is still febrile o Important Concept!  Therefore, give antipyretic round 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  Presence of Pathological Vascular Changes o Petechiae o Hermans Sign  Generalized redness  Flushing of the skin INFECTED MOSQUITO BLOODSTREAM (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!  If patient recovers, he only has Dengue Fever (and not Dengue Hemorrhagic Fever)  Dengue Fever is also called: o Dandy Fever o Breakbone Fever

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 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 o How?  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 o Indicators of Circulatory Failure:  Hypotension or decreased blood pressure  Rapid but weak pulse  Rapid respiration DHF Grade 4  With signs and symptoms of DHF Grade 3  With shock  Hypovolemic shock due to excessive blood loss due to uncontrolled bleeding Diagnostic Tests for Dengue Hemorrhagic Fever 1. Tourniquet or Rumpel Leedes 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

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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. . . 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 Reyes Syndrome y A neurologic disorder associated with viral infection  If there is bleeding o Give coagulants  Vitamin K y Aquamephyton y Konakion o

 Vitamin C To increase capillary resistance  Provide blood transfusion Nursing Management  Prioritize bleeding prevention and control  For gum bleeding o Use cotton swab o This is softer than any toothbrush  Provide ice chips  Advise patient to gargle o It will not cause injury o Use mouthwash  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  Blood is needed by the female 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 It breeds in CLEAR, SLOW FLOWING WATER o It is common in

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Rural Areas Mountainous Areas Forested Areas y Palawan y Dumaguete y Surigao It lands on the surface on a forty-five (45) degree angle or in a slanting position   

Pathophysiology of Malaria PLASMODIUM BLOODSTREAM Inside RBC (for reproduction) Those that dont 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!  Rupturing of membranes of Plasmodium coincides with the presence of CHILLS in the patient  Presence of more or new 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  Malaria can also be obtained by BLOOD TRANSFUSION Manifestations of Malaria 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 o Expose to heat lamp or 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 o Feeling of weakness  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!!!  In other types of sicknesses or disorders, chills occur before fever  This is due to bodys response to heat loss  In ordinary infections, higher temperatures are seen during CHILLS because patient is trying to retain heat  In malaria, increased temperature 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

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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!  During the Hot Stage, the microorganism is in the bloodstream  During the Cold Stage, the 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 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)

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 OF THE INTEGUMENTARY SYSTEM Viral Communicable Diseases  Measles  German Measles  Chicken Pox  Herpes Zoster MEASLES Causative Agent  Morbilli o Paramyxovirus  Rubeola Virus Manifestations of Measles 1. Pre-eruptive Stage  Three (3) Cs 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 3RD 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  Peeling off proceeds in a cephalocaudal manner

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 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 o Use of colantro is now discouraged Diagnostic Tests for Measles 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 patients 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  However, do not expose the patient to draft Other Nursing Care  Symptomatic nursing care  Patient is photophobic

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 patients body has produced anti-bodies to measles 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  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

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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) 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 o Therefore, he only has two (2) Cs.  Important Concept! o Enanthem of German Measles are called FORSCHEIMER SPOTS  Fine red spots  Also called petechial spots  Appears on the soft palate 2nd 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

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 3rd Stage Post-Eruptive Stage  Rashes now start to disappear  But they disappear at the third (3rd) 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 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  When is German Measles 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.

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 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 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 CHICKEN POX  Also called Varicella Causative Agent  Varicella Zoster Virus o Can be found both on:  Nasopharyngeal Secretions  Secretions of rashes o But only causes infection if. . .  It enters the nasopharynx o Does NOT cause infection by skin to skin contact Mode of Transmission  Airborne 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 forty-eight (48) hours Stage 2 Eruptive Stage  Presence of rashes o Vesiculopustular rashes  Development of Vesiculopustular 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  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!!! SCRATCHING WHILE ASLEEP RUPTURES THE VESICLES Leads to skin Infection 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 o 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 Permanent Scar (Pox mark)

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 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 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  Symptomatic management as 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 o Dosage is four (4) to five (5) tablets per day for one week  Zovirax Cream o Protects skin from infection but does not protect against pox marks  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!  Attack of Chicken Pox gives 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 2.Proper disposal of nasopharyngeal secretions 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  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 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

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 Application of Potassium Permanganate (KMnO4) compress over the rashes of the patient  Rationale: o To obtain three-fold effect  Astringent effect y To dry the rashes  Bactericidal effect y To decrease chances of skin infection  Oxidizing effect y 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 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 o Wound Diphtheria  Affects wounds  Especially of burn patients

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 o Like cigarette ash  Patient also has a BULL NECK 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

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 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 y Difficulty of breathing  Body compensates and uses 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 The patient is not breast-feeding (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

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. Schicks Test  Test for immunity or susceptibility to diphtheria 2. Moloney Test  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: 1. Neutralize the toxin  The toxin brings about systemic 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  Also have ready and handy the following: o Epinephrine o Corticosteroid 2. Kill microorganism  Give anti-biotics  Drug of Choice o Penicillin  Important Concept!

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 Scraping the pseudomembrane does not kill the microorganism  It only causes bleeding 3.Prevent Respiratory Obstruction  Performance of emergency 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 o 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 hearts resistance to go down:  When the heart is overloaded with work  When the heart is under stressful activities  Therefore, provide COMPLETE BED REST 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-Fowlers  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 doctors order. o Nebulization o Steam Inhalation  Perform Postural Drainage with doctors 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  When patient is unsuccessful in expectorating narrow passageway requires long inhalation  If patient keeps on coughing o He may choke on his mucous o This results to vomiting o 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

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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 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 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

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!  No permanent immunity from an 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) TUBERCULOSIS  Also called o Kochs infection o Phthisis o Galloping Consumption o Pulmonary Tuberculosis Causative Agent  Mycobacterium tuberculosis o 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

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 Symptoms are usually seen after four (4) to eight (8) weeks. 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 Three (3) Classifications of Patients 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 o Far Advanced Pulmonary 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 TB0      TB1 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  Positive ( + ) to TB exposure  Positive ( + ) to TB infection 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

 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 o INH o Isoniazid  The most effective TB drug  Side Effect y 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 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 Combination of Anti-Tuberculosis drugs to prevent drug resistance  Short-Course Chemotherapy o Composed of RIP(E)  Rifampicin  Isoniazid  Pyrazinamide  Ethambutol y May or may not be given  Standard Regimen o Composed of SI(E)  Streptomycin  Isoniazid  Ethambutol y May or may not be given Important Concepts!!!  Short-Course Chemotherapy Side Effects  Causes hepatotoxicity  Nursing Management o Therefore, monitor liver enzyme tests  Advise patient to avoid alcoholic beverages, which increase hepatotoxic effects       

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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  Nursing Management o Give Vitamin B6 or pyridoxine Pyrazinamide PZA  Side effect is hyperuricemia  Patient is predisposed to stone 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  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!  The American Pulmonary Society classification is the best classification!!!

Diagnostic Examinations for Tuberculosis 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 fortyeight (48) to seventy-two (72) hours o A positive result would give you 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  Utilizes the same technique as a skin test  Uses PPD  Interpreted after forty-eight (48) to seventy-two (72) hours  Positive result is bigger wheal 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

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o o

Less pain to patient Most accurate results

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!!! o 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 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 Preventive Measures 1. Immunization  Bacillus Calmette Guerin (BCG) vaccine  Number of Doses: o Two  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!!!

Do not massage site of injection Rationale:  It will spill the drug o Child may experience fever  Nursing Management 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 y Given subcutaneously instead of intradermally y Childs 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 o 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  Common opportunistic infection in AIDS  Protozoa o Pneumocystis carinii Pneumonia

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Also a common infection in AIDS

opportunistic

 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 o Aggravated when coughing o Use of chest binder is encouraged Important Concepts!!! Presence of fast breathing is common in Pneumonia 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!  Check for the presence of the 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 Diagnostic Tests for Pneumonia 1. Chest X-ray  Expect infiltrations  Lung consolidation  This is the confirmatory examination 2. Sputum Examination  Purpose is to know what microorganism brought pneumonia 3. Auscultation  For crackles  For ronchi o Decreased vocal fremitus  Ninety-nine verbalized o Decreased breath sounds 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.) 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  For prevention of secondary pneumonia  Given to adults

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 Given to the elderly with Community-Acquired Pneumonia (CAP) 2. Proper disposal of nasopharyngeal secretions 3. Cover the nose and mouth while coughing or sneezing o COMMUNICABLE DISEASES OF THE GASTROINTESTINAL TRACT Bacterial  Gastroenteritis  Inflammation of the gastric mucosa and the mucosa of the intestines Key Concepts!  Main Sign and Symptom of Gastroenteritis is diarrhea  Diarrhea is a general term caused by various microorganisms Causative Agents:  Salmonella typhosa o For typhoid fever  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

o  Botulism o Caused by canned or preserved foods o 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  Microorganisms endotoxin destroys the intestinal wall 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 womans 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  Number 1 indicator of dehydration in a patient with diarrhea is LOSS OF WEIGHT o

 Rice  Pastries  Bread  Cakes  Pasta  Noodles Incubation Period  Two (2) to six (6) hours Then you manifest the symptoms

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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 o Diagnostic Tests for Patients with Gastroenteritis 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 o This drug gives rise to bone marrow depression, which leads to anemia and even leukemia  In dysentery, particularly bacillary 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  Sunlight destroys component of tetracycline Important Concept!  Gastroenteritis attack does not give permanent immunity Preventive Management 1. Immunization  CDT immunization  Given only free during epidemic  Provides six (6) months immunity 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 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 LEPTOSPIROSIS  Also called o Mud Fever o Swamp Fever o Canicola Fever o Pre-tibia o Weils Disease o Swine Herds Disease o Ictero-hemorrhagic disease  A disease of a low form of animal found in the farm

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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 Mode of Transmission  Skin penetration Important Concept!  No need to have a break in the skin or to have a wound to have leptospirosis Individuals who are High-Risk for Leptospirosis:  Sewage Workers o Those working in drainage systems  Farmers  Miners  Slaughterhouse workers (pigs, cattle are sources of infection)  Manilenos o Due to flooding  Incidence of leptospirosis increases during the rainy season 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 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  For ictero-hemorrhagic type of leptospirosis: o Jaundice

Hemorrhages membrane

on

skin

and

mucous

Important Concept!  Pathognomonic sign of leptospirosis are the orange eyes or orange sclera of the eyes Important Concept!  If the kidney is affected, there would be signs and symptoms of kidney failure: o Decreased urine output o Leading to anuria Diagnostic Tests for Leptospirosis  Blood Examinations o Leptospira Agglutination Test (LAT) o Leptospira Antigen-Antibody Test (LAAT) o Microscopic Agglutination Test (MAT)  Reveals the microorganism Medical Management of Leptospirosis Anti-biotics  Drug of Choice is TETRACYCLINE  If patient does not tolerate 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!!! 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 Preventive Measures  Eradicate rats by environmental 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

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o Causative Agent  Paramyxovirus o 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  Symptomatic as the causative organism is viral  Recovery depends on nursing care provided 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!  Glandular complications are 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 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

Bland diet  Sour and spicy foods are irritating  They increase salivation and increase pain  Thus, kalamansi is contraindicated for mumps patients Apple juice and water are allowed in mumps patients

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!  Mumps attack gives permanent 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 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 o Microorganisms  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

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 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  Rarely percutaneous or by blood transmission 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 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

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 B:  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  Six (6) weeks to six (6) months 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

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 Delta virus Important Concept!  In Hepatitis D infected individuals o 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 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 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 Incubation Period:  Two (2) to six (6) weeks

HEPATITIS G  No synonyms Causative Agent  Hepatitis G virus Important Concept!  In individuals with Hepatitis G o The Blood  Harbors the microorganism Mode of Transmission  Percutaneous 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 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 o Above three (3) manifestations are due to inability of the liver to deaminase proteins  Anemia  Paleness  Pallor

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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 2nd Stage Icteric Stage o 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 3rd Stage Post-Icteric Stage  Jaundice disappears  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. 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 First enzyme to increase in the presence of a liver problem 1.2) AST  Aspartate Transaminase  Formerly SGOT  Serum Glutamic-Oxaloacetic Transaminase  Increases only upon the onset of jaundice 1.3) ALP  Alkaline Phosphatase  Increase indicates: o Obstructive Jaundice o Obstructive Hepatitis 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 1.5) LDH  Lactate Dehydrogenase  When identified, it indicates liver organ damage     

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

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Most Common Drugs used in Hepatitis:  Essentiale  Jetipar  Silymarine o The above three (3) drugs are:  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:  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 1. Provide Complete Bed Rest (CBR)  To promote liver regeneration and recovery  When rested, there is decreased metabolism  Less metabolism leads to decreased liver load  Liver relaxes and liver recovers 2. Diet  Low fat diet o Because there is not enough 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 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 Preventive Measures for Hepatitis 1. Immunization  Hepatitis B vaccine  Number of Doses: o Three (3)  Interval between doses: o Four (4) weeks  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  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.

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COMMUNICABLE DISEASES OF THE GENITOURINARY SYSTEM SEXUALLY TRANSMITTED DISEASES Bacterial  Gonorrhea  Syphilis Viral  HIV Infection  AIDS GONORRHEA  Also called  Clap  Microorganism resembles hands 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  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  Presence or absence of purulent discharges  Important Concept!

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 Bartholins Gland or the Skeenes 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: y Fever y Severe abdominal pain y Nausea and Vomiting y This is secondary to gonococcal infections  Sterility and Ectopic Pregnancy o If gonorrhea persists, it causes a narrowing of the Fallopian Tube  Gonococcal Septicemia o Occurs when gonorrhea is already systemic o Signs and symptoms would include:  Presence of Gonococcal Rashes  Papular y Elevated Rashes  Pustular y 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 CREEDES PROPHYLAXIS to prevent blindness in the newborn Diagnostic Tests for Gonorrhea o 1. Culture and Sensitivity  Collect urethral discharges  Done by scraping mucosa of the urethra 2. Papanicolaus Smear or Vaginal Smear  For females Medical Management of Gonorrhea 1. Anti-biotics  Drug of Choice

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Penicillin Benzathine Pen G (Penadur) 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:  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 Administer SPECTINOMYCIN 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 o Administer DOXYCYCLINE instead!!! o o o 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 Education and Patient Teaching  To prevent recurrence of infection 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 o Sy 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  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

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 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 o Some are in the form of infiltrating tumors  Other organs of the body are also affected o Most commonly affected is the HEART o This gives rise to CARDIOVASCULAR SYPHILIS  Neurosyphilis o Central Nervous System affectation o Neurologic symptoms are present  Lack of Balance  Dementia 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 o This is not a definitive test 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! o If I.M. preparation is given via I.V.  Patient dies due to dysrhythmias o 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!!!  Effect of syphilis to child whose 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:  Hutchinsons Teeth y Saw-like teeth  Anterior Bowing of the Tibia y Fractured Tibia y 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  Child will eventually die

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 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 Important Concepts!!!  If you are pregnant, do not be infected with syphilis  Do not get infected with syphilis, particularly in the third (3rd) 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!!!  Acquired Immune Deficiency 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 (56C) o Chlorine  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

But if the virus goes out with blood, the VIRUS WILL REMAIN ALIVE, as long as the BLOOD IS FRESH!!! Once a person dies with AIDS, the virus remains in the body of the individual, as long as, the body is HUMID 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. The body of an AIDS victim COULD NOT BE EMBALMED  The virus will INFECT THE EMBALMERS

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  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 o Therefore, child is positive for 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

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Alerted T cells reproduce and multiply T cells stimulate the B cells B cells reproduce and multiply B cells release the antibody

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

Antibody produced attacks the invading microorganism Antigen-Antibody reaction occurs Infected with HIV but is ASYMPTOMATIC Manifestation of Disease will be present Important Concept!  In HIV Infection, there is an alteration in the NORMAL Immune Response 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 ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) T cell BECOMES a PRO-VIRUS Virus multiplies within the T cell T cell is DAMAGED DEATH occurs 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 Manifestations of AIDS  For adults 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 Months to years ( + ) for HIV infection With AID Related Complex (ARC) Symptoms Months to years 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

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o Two (2) major symptoms o One (1) minor symptom  For Children o Two (2) major symptoms o Two (2) minor symptoms 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  Persistent generalized lymphadenopathy  Generalized pruritic dermatitis  Persistent cough: One (1) month and above  Oropharyngeal Candidiasis  Recurrent Herpes Zoster  Progressive Disseminated Herpes Simplex  Continually multiplying and continually growing mouth sores 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 o Has less chances of becoming 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 o Then, that child is AIDS BONAFIDE Key Concepts!  When a person has AIDS, all microorganisms entering his body gives rise to infections  These are called OPPORTUNISTIC 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-Hodgkins Disease  Cancer of the lymph nodes Diagnostic Tests for AIDS 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 o Monitors replicating activity of the virus o Negative ( - ) Viral Load  Means virus is not actively multiplying but is still present o 3.2) CD4 and T cell Count o Establishes STAGE OF INFECTION, whether it is HIV or AIDS  Indicates HIV infection y If greater than or equal to 200  Indicates AIDS y If less than 200 Medical Management for AIDS  Symptomatic management as virus is the causative agent  Latest Trend in Pharmacologic Management of AIDS o COCKTAIL DRUGS  Patient must take medication composed of at least twenty-one (21) tablets per day

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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 y Tastes sour y Give together with fruit juice o Lamivudine o Stavudine  2.Non-nucleoside Reverse Transcriptase Inhibitors  Non-NRTIs o Delavirdine o Nevirapine 3. Protease Inhibitors  PIs o Saquinavir o Indinavir o Pitonavir o Delfinavir Important Concept!  All of the abovementioned drugs inhibit multiplication of the virus but DOES NOT KILL THE VIRUS Nursing Care for AIDS  Symptomatic as causative agent is a virus  Psychological Care  Promotion of Homeostasis Important Concept!  Role of the Nurse in AIDS o A counselor Preventive Measures  A for Abstinence  B for Be Truthful  C for Condom use  D for Do not use Drugs Important Concept!

 Virus can be found on all body fluids but will not be enough to cause infections  Example: o Six (6) to eight (8) gallons of saliva are needed to transmit HIV

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