MODULE 1 - PROBLEMS ON IMMUNOLOGIC AND INFLAMMATORY RESPONSE

KNOWLEDGE OBJECTIVES:
In the care of patients with immunologic and inflammatory alterations, the learners will be
able to:

1. Apply knowledge on health and natural sciences, anatomy and physiology, and
pharmacology.
2. Identify significant assessment findings and pathognomonic signs of the alterations using
comprehensive history taking, inspection, palpation, percussion, and auscultation.
3. Discuss the indication and rationale and preparation for the diagnostic examinations.
4. Trace the pathophysiology, including the predisposing and precipitating factors, disease
process, and signs and symptoms of the patients.
5. Describe the independent, dependent, and collaborative management in the care of the
patients.
6. Prepare a nursing care plan applying the nursing process assessment, diagnosis,
planning, implementation, and evaluation.

MODULE OUTLINE:

A. BASIC CONCEPTS

 The human body’s internal environment works best when invaders from the external world
are destroyed, inactivated or confined. Inflammation and the immune system work with
other defenses to provide protection from harmful microorganism and cells.
 Immune function is reduced by many diseases, injuries and medical therapies. Reduction of
immune function may be temporary or permanent.

 IMMUNITY - Composed of functions that protect humans against the side effects that
accompany invasion of or injury to the body.

 People interact with many other living organisms in the environment and they vary in size
from large (other human and animal) to microscopic (bacteria, viruses, molds, spores,
pollens, protozoa and cells from other people or animal). As long as organisms do not enter
the internal environment, they pose no threat to health.

 PURPOSE OF THE CELLS THAT COMPOSE THE IMMUNE SYSTEM is to: neutralize, eliminate, or
destroy microorganisms.

 Immune system can differentiate between the body’s own, healthy self cells and other non-self
proteins and cells.
 Self-tolerance is the ability to recognize self versus non-self  necessary to prevent healthy body
cells from being destroyed along with the invaders.
INFLAMMATION OR INFLAMMATORY RESPONSE

Inflammation – also called natural immunity, provides immediate protection against the effects of
tissue injury and invading foreign proteins.

 The body’s response to injury

 A nonspecific response to invasion or injury.

Purposes: The ability to produce an inflammatory response which is critical to health and well-
being.
 control of bleeding
 wound sealing

Major Physiologic Responses: vascular; cellular; chemical; fibrin barrier wall; humoral and
hormonal responses.

Three Distinct Functional Stages:

a) Stage I - vascular stage – early effects involve changes in the blood vessels. It causes redness &
warmth of the tissues. Blood flow to the area increases (Hyperemia) and edema (swelling)
forms at the site of injury.
b) Stage II - cellular exudate phase – in this stage, Neutrophilia (an increase number of circulating
neutrophils) occurs. Exudates in the form of pus occurs containing dead WBCs, necrotic tissues
and fluids that escaped from damaged cells.
c) Stage III - tissue repair and replacement phase – begins at the time of injury and is critical to the
final function of the inflamed area.

LOCAL AND SYSTEMIC MANIFESTATIONS:

a) Local - Cardinal Signs of redness, heat, swelling, pain and loss of function.
b) Systemic - fever, malaise, weakness, anorexia, leukocytosis and increased ESR, etc.

CELLULAR COMPONENTS:
a) Neutrophils and macrophages – phagocytosis, make up between 55% & 70% of the normal total
WBC count. It provides protection after invaders (esp. bacteria) enters the body.
b) Eosinophils and Basophils - act on specific cells within the vascular system to initiate tissue-
level inflammatory responses.
* Eosinophils come from the myeloid line, only 1% to 2% of the total WBC count.
* Basophils make up only about 1% of the total circulating WBC count.

 IMMUNE RESPONSE - represents the body’s way of recognizing and destroying antigens

➪ FUNCTIONS of immune response: Defense; Homeostasis; Surveillance

➪ PROPERTIES: specificity (quality of being clear and exact); memory; heterogeneity (uniformity
in composition or character)

➪ TYPES OF REACTIONS:
  Humoral Immunity or Antibody-mediated immunity (AMI) – involves antigen-antibody
interactions to neutralize, eliminate or destroy foreign proteins. Antibodies are
produced by B-Lymphocytes (B-cells).
* For optimal AMI, the entire immune system must function adequately.

 Cell-mediated Immunity (CMI) – involves many WBC actions and interactions. This type
of immunity is provided by the lymphocyte stem cells.

➪ TIME COURSE: Primary; Secondary

➪ TYPES OF IMMUNITY:
 Specific/Nonspecific – comprises the cells and mechanisms that defend the host from
infestations by other organism in a non-specific manner. It is the first line of defense.
 Natural/Acquired – when a person exposed to an infection (antigen) developed against
that disease is naturally induced immunity or autoimmune response.
 Active/Passive – the use of vaccine which stimulates production of antibodies (long
lasting).

 DEVASTATING EFFECTS OF AN ABNORMALLY FUNCTIONING IMMUNE SYSTEM

➪ Misdirected immune responses - “autoimmune reactions”
➪ Immune hyperactivity – too much
➪ Immunodeficiency – too little
➪ Failure of Surveillance

 LYMPHOID SYSTEM – is part of the circulatory system comprising a network of lymphatic vessels
that carry a clear fluid called Lymph directly to the heart.
Functions:
 To provide accessory route for these excess 3 liters/day to get returned to the blood.
 Other main function is that of defense in the immune system.

= Primary Lymphoid Organs/tissues – Thymus and bone marrow

= Secondary Lymphoid Organs/tissues – Lymph nodes and the spleen

CELLS OF THE LYMPHOID SYSTEM

 B-Lymphocytes (B-cells) – matures in the bone marrow
 T- Lymphocytes (T-cells) – mature in the thymus gland.
 Other blood cells:
a) Monocytes and Leukocytes – are produced in the bone marrow
b) Tissue macrophages- histiocytes along the lymphatic veins.

B. ASSESSMENT OF THE CLIENT

1. Subjective Data- Obtain from:

➣ Nursing History- focusing on:

 chief complaints
 relevant information, such as allergies include food, medication, insect or pollen
sensitivities.
 Past medical history- previous treatment and hospitalization
 Family history- ask patient to identify allergies and sensitivities in the family
 Psychosocial history- include lifestyle, information about the client’s physical
environment, stress management
 ➣ Review of Systems

2. Objective Data - should include:

a) Physical Appearance - for

 Signs of an acute illness
 Signs of a chronic illness
 Note the patient’s facial features, observe the patient’s posture, movements, and gait
for abnormalities

b) Assess Vital Signs- baseline data

 Fever- with or without chill suggests infection
 Subnormal temperature- occurs in gram-negative infections
 Other signs of inflammation such as redness, swellings, or tenderness may accompany a fever

c) Physical Examination- Techniques used include:

 Inspection- areas such as:

1) Skin color -
➣ Basic skin color is the result of the following physiologic determinants-superficial capillaries
and venous plexuses; melanin; and melanoid and carotene
➣ Natural pallor
➣ Abnormal pallor and flushing

 Palms are excellent sites for assessing the presence and even the degree of pallor, unless
they are calloused and have heavy deposits of carotene.
➣ Pallor of extremities
➣ Cyanosis
➣ Abnormal flushing

Pigmentation - The yellow, brown and black

skin colors provided primarily by the melanocytes
➣ Jaundice
➪ Influence of edema on the skin color

2) Nails
 Assessment includes inspection for variations from the normally uniform pink color of the
nail bed; in the shape and continuity of the nails; in the angle at the junction of the nail fold and
nail plate; and in the thickness and transparency of the nails.
➪ Check for capillary filling time
➪ The nail bed, when not pigmented, readily demonstrate cyanosis

3) Hair- normal color, texture and amount of hair varies considerably according to genetic
and age determinants

4) Mucous Membranes
 Hard palate- an excellent site for detecting jaundice
 Signs of illness often seen during inspection of the mucous membranes, such as:
 ➪ Koplik spots of measles
➪ Pigmentation of lips and buccal mucosa in Addison’s disease
➪ Peutz-Jeghers syndrome- beefy tongue in pernicious anemia
➪ White membranous plaque or monilia (thrush)
 Although the genital mucosa is not readily accessible for inspection as well as social taboos
create additional restraints, it should be included in the physical examination.

5) Conjunctiva- can help in the assessment of cyanosis and pallor

6) Presence of Foreign body especially when inflammation of the skin is present, particularly
following a trauma.

7) Swelling/Edema; Emphysema

8) Lesion or Rashes
 Types and components of rashes:
➣ Primary - vesicles, macules, papules, plaques, nodules, wheals, pustules
➣ Secondary - crusts, scales, fissures, excoriation, erosions, ulcers, scar

 Palpation

1) Skin - assess for

➣ Texture “the feel of the skin,” its smoothness and softness
 Smoothness
 Softness
 Use finger pads to feel texture better.
➣ Configuration
➣ Temperature
➣ Elasticity
➣ Moisture

2) Lymph Nodes - use pads of index and middle fingers to assess superficial lymph nodes such as
that in the head, neck, axillary, epitrochlear, inguinal, popliteal

3) Spleen - palpate only after percussion is done.

 Percussion - When assessing the immune system, percuss and palpate the spleen - done to
estimate its size.

d) Diagnostic Examinations:

1) Noninvasive -
 Chest X-ray
 Sputum Examination
 Gram Stain and Culture

2) Invasive -
 Laboratory Blood Tests - such as WBC with differential count ESR, Platelet count, VDRL, Tests
for streptococcal antibodies; HIV testing- Western Blot and ELISA)
  Patch and Scratch Test:
= A microscopic amount of an allergen is introduced to a patient’s skin by various means:
 Prick Test or Scratch test – pricking the skin with needle or pin containing small amount of
allergen.
 Patch test – applying of patch to the skin, where the patch contains allergen.

 Intradermal Test- e.g. Tuberculin test or Mantoux test, Tine test, Skin test with allergenic
antigens or allergens

 KOH Preparation- helps identify fungal infections

 Tzanck Test- to help confirm herpes virus infection

 Skin Biopsy- uses shave, punch or excision technic to confirm malignancies and other
dermatoses

C. SPECIFIC DISORDERS

PATHOPHYSIOLOGICAL CHANGES DURING AN INFLAMMATORY/ INFECTIOUS PROCESS

 FACTORS FOR DEVELOPMENT OF THE INFECTIOUS DISEASE PROCESS

➣ Causative Agent  Reservoir for the causative agent  Mode of Escape for Transmission 
Mode of Transmission from reservoir to new host  Mode of Entry into new host 
Susceptible Host

➪ Bacteria produce disease either by invasion of tissues or elaboration of toxins

(endotoxin/exotoxins).
➪ Viruses damage host cells by direct invasion.

A. PULMONARY TUBERCULOSIS - caused by Mycobacterium tuberculosis; characterized by

pulmonary infiltrates; granuloma formation with caseation; fibrosis and cavitations.
 Mode of Transmission: droplet infection; airborne

Risk Factors: Close contact with infected person; Immunocompromised status; Substance
abuse; Being a healthcare provider

 ASSESSMENT FINDINGS:

 Late afternoon fever

 Night sweats
 Cough- initially dry productive purulent and /or blood-tinged sputum
 Malaise; Anorexia; Nausea; Weight Loss
 Hemoptysis
 Positive Sputum Exam, Tuberculin test and Chest X-ray

For Elderly:
= Signs and symptoms: Altered mental status, fever, anorexia, weight loss.
Classifications of Tuberculosis:

5 Classes:

Class 1 – TB exposure, no evidence of infection

Class 2 – TB infection, no disease, (+) PPD
Class 3 – TB clinically active (patients with completed diagnostic evidence of TB – both a significant
reaction to TB skin test and clinical or x-ray evidence of TB)
Class 4 – TB, not clinically active (patients with history of TB or abnormal chest x-ray but no
significant Tb skin test reaction or clinical evidence)
Class 5 – TB; suspected (diagnosis pending); used during diagnostic testing of suspect patients for
no longer than 3 months

Complications:

 Extrapulmonary TB – prevalent in HIV-infected persons

 Miliary TB- primary tuberculosis lesions erode into the blood vessels and the bacteria is spread
throughout the body, bone marrow is involved
 GU TB- involves kidney and GU tract
 TB Meningitis – mycobacterium tuberculosis infection of the meninges
 Skeletal TB – bones and joints

Collaborative Care:

 Screening Methods- Intradermal PPD; Tine test (a multiple puncture tuberculin skin test used to
aid in the medical diagnosis of TB)
 Diagnostic Tests- Sputum for AFB; Positive cultures; Chest X-ray

 Drug Therapy- combination drug therapy is the most effective method of treating TB and
preventing transmission.

 Anti-TB agents (6-12 months)

1. Isoniazid (INH) – bactericidal with pyridoxine  avoid tyramine (cheese and wine).
2. Rifampin (Rifadin) – avoid tyramine  orange colored urine and discoloring of lenses
3. Pyrazinamide (PZA) – avoid tyramine and monitor uric acid. Added for the 1st 2 months.
This protocol shortens the therapy from 6 to 12 months to 6 months.
4. Ethambutol (EMB; Myambutol) – bacteriostatic, contraindicated on renal diseases 
monitor visual acuity.

 Surgery – resection of infected lung

Nursing Interventions:
 Focus on patient teaching for drug therapy adherence and infection control.
 TB drugs may cause nausea
= Teach client to prevent nausea by taking the daily dose at bedtime.
= Antiemetics may be used to prevent the problem.
 A well-balanced diet – to promote healing
= Increase intake of foods that are rich in Iron, protein and Vitamins C & B.

Nursing Diagnosis and Management:

 Knowledge Deficit- assess client’s level of knowledge about the disorder; establish a relationship of
mutual trust; teach client about the disease and therapeutic regimen.

 Risk for Infection- use standard precaution; inform client about the reasons for and importance in
carrying out respiratory isolation; prevention of transmission.

 Activity Intolerance- provide rest periods in between nursing activities

 Ineffective Airway Clearance- Teach how to produce and effective cough; suctioning.

 Altered Nutrition; Less than body requirements - emphasize importance of proper diet; small
frequent feedings; provide hi-caloric diet.

INFLAMMATORY SKIN DISTURBANCES DUE TO VIRAL INFECTIONS

A) HERPES SIMPLEX – fever blister or cold sores.

 Etiology: 2 types of Herpes Virus Hominis

 Type I (Orolabial Herpes) – known as fever blisters, yellow crusts or cold sores. Responsible
for Herpes Labiales, and causes infections above the waist, involving
gingiva, the dermis, the URTs and CNS.
 Type II (Genital Herpes) - Herpes Progenitalis  location below the waist.

 Mode of Transmission: Direct (physical contact, oral sex or direct kissing)

 Assessment Findings:

a) Burning, tingling, itchiness occurring on the lips or any area around the mouth
b) Eruption of multiple grouped tiny vesicles on an erythematous base Crusting occurs about
48 hours.
➣ Initial infection- often severe and accompanied by systemic manifestations, such as fever and
sore throat; recurrences are more localized and less severe.
➣ The virus lives in nerve ganglia and may cause recurrent lesions in response to sunlight,
menstruation and stress.

Collaborative Care:

1) Laboratory and Diagnostic Tests

 Tzanck smear
 Cultures from lesions
 Immunofluorescent methods

2) Pharmacology
 Acyclovir- shortens time of symptoms and speeds healing
= Codeine or aspirin – pain

Management:

1. Good genital hygiene

 2. Wearing of loose-fitting cotton undergarments
3. Lesions must be kept dry
4. Sitz bath
5. Abstain from sexual contact while lesions are present
6. Use of condom

Nursing Diagnoses:

➪ Pain
➪ Sleep Pattern Disturbance
➪ Risk for Infection

B. HERPES ZOSTER/SHINGLES

Causative Agent: Varicella-zoster virus (VZV)

 Product of Chicken Pox

 Painful vesicular eruption, along localized area of distribution
 VZV – responsible for the outbreak which lies dormant inside nerve cells near the brain and
spinal cord.
 VZV when activated, they travel by way of peripheral nerve to the skin and create red rash of
small, fluid-filled blister.
Signs and Symptoms:

 Tingling and pain – radiate over entire region, supplied by the affected nerves.
= Burning, lacerating (tearing), stabbing and aching.
 Itching and tenderness
 Malaise and GI disturbances
 Grouped vesicles – red and swollen
= Blisters – common on the torso and face
= Shingles – painful rah often appears around the rib cage or waist
= Eruption occurs after several days of discomfort
 Eye pain – ophthalmic nerve is involved.

Clinical Course: 1 – 3 weeks

Healing Time: 7 – 26 days

Complications:

 Postherpetic Neuralgia,
 Infection
 Scarring
 Full thickness skin necrosis
 Bell’s Palsy
 Eye infection
Medical Management:

 Pain medications
 Systemic corticosteroids – decrease neuralgia
 Triamemolone – anti-inflammatory
 Acyclovir, Valacyclovir, Famiclovir - antiviral
 Severe: Ophthalmic Herpes Zoster
= Emergency – refer to Ophthalmologist ASAP.

Nursing Management:

 Assess pain level daily

 Proper hand hygiene
 Diversionary activities, relaxation techniques

SEXUALLY TRANSMITTED GENITOURINARY TRACT INFECTIONS

A) SYPHILIS - “Bad Blood,” Lues, Pox

Syphilis – a chronic infectious disease that enters the body thru mucous membrane or breaks in
the skin and spreads to the nearby lymph nodes (local infection) and bloodstream (systemic
infection).

 Etiologic Agent: Treponema pallidum

 Mode of Transmission: Sexual Contact; Fetus placental Transmission; Blood transfusion; sharing
of needles.

 Portals of Entry: External genitalia, cervix, mouth, perianal area, anal canal

 Incubation Period: 10 days to three months (averaging 20-30 days).

 Four Stages (clinical) characterizing untreated syphilis: Primary, Secondary, Latent, and Late.

Assessment Findings: (According to Clinical Stages)

1) Primary Stage- Chancre and Enlarged regional lymph nodes (lymphadenopathy). If untreated
heals 4-6 weeks.
2) Secondary Stage – begins from 2-8 weeks after chancre disappears. Develops if primary stage is
left untreated. Causing generalized or localized skin eruptions; mucous patches; generalized
painless lymphadenopathy; condylomata lata; alopecia of scalp, eyebrows, eyelashes and beard;
flu-like syndrome.

3) Latent stage syphilis- no signs and symptoms of syphilis during this time. This is the time where
immune system suppresses the infection.
 Early Latent- asymptomatic for less than 4 years (less contagious)
 Late Latent- asymptomatic syphilis of more than 4 years duration

4) Late stage syphilis- Gumma (infiltrating tumors), Lesions on the skin and mucous membrane;
cardiovascular syphilis; neurosyphilis  meningitis.
 ➪ CONGENITAL SYPHILIS - An infection transmitted transplacentally, that occurs in infants of
untreated or inadequately treated mothers.

Assessment Findings:

1) S/S affecting skin and mucous membranes- snuffles; mucous membrane patches;
maculopapular rashes; condylomas
2) Interstitial keratitis – infections of the cornea
3) Hutchinson’s teeth – screw-driver like teeth
4) Saddle nose – no nose bridge
5) Saber shins – a malformation of the tibia resulting from hereditary syphilis.
6) CNS involvement  causing deafness.

Collaborative Care:

1) Laboratory and Diagnostic Tests

 (+) VDRL and (+) RPR (rapid plasma reagent) - measure antibody production)
 Immunofluorescent staining
 (+) Darkfield microscopy – this test confirms a diagnosis of syphilis when other test resulted to
genitally negative.
2) Pharmacology
 Penicillin (Tetracycline) – drug of choice given IM or IV for early syphilis (Primary stage).
= Doxycycline if allergic to Penicillin G

Implementation:

 Good personal hygiene

 Education of the disease
 Administer long acting Benzathine, Penicillin G.
 Avoid sexual contact
 Dispose contaminated materials properly

Nursing Diagnosis and Management:

 Risk for injury (complications)- teach importance of taking any prescribed oral medications;
importance of follow-up.
 Self-esteem disturbance - Create an environment where client feels respected and safe to
discuss questions and concerns; Provide privacy and confidentiality; Let client know that nurse
and other health care provider care about the client and the successful treatment.
 Anxiety- Emphasize that syphilis can be effectively treated, preventing the serious
complications of the late stage disease.

B) GONORRHEA “The Clap” or “GC” - a common STD affecting the GUT especially the urethra, cervix
and occasionally the rectum, pharynx and the eyes.

 Etiologic Agent: Neisseria Gonorrhea (a gram-negative diplococcus)

 Mode of Transmission: Direct sexual contact;
= In the fetus- direct contact with infected maternal tissues during delivery  Ophthalmia
Neonatorum.

Assessment Findings:

1) In the males- (appearing 2 – 6 days after exposure) – Irritation of urethral meatus, with clear
mucous discharge becoming profuse, thick and purulent; Painful and burning sensation in the
penis during urination; Reddened penis – swollen and tender to touch.
Complications: Epididymitis and Prostatitis

2) In the females (tends to be chronic)- Purulent yellow discharge; Red, swollen, tender vulva;
Burning, frequency and urgency of urination; anorectal discomfort and purulent drainage from
the rectum; Bartholin’s abscess.
Complications: Salpingitis and PID  infertility.

3) Anorectal Infections (Proctitis)

4) Pharyngeal Infections (Pharyngitis) - sore throat with exudates; enlarged, tender cervical lymph
nodes
5) Gonococcal conjunctivitis

Collaborative Care:

1) Laboratory and Diagnostic Tests

 Smear of urethral discharges

2) Pharmacology
 Antibiotics such as penicillin, cefixime, ciprofloxacin, azithromycin (Zithromax)
= Child – given IM, thigh
= Adult – butt
 Routine instillation of 1% silver nitrate or Erythromycin (Romycin) for gonococcal ophthalmic
neonatorum  results to blindness.

Nursing Management:

 Warn the patient to avoid sex.

 Treatment of sexual disease.
 Avoid sexual contact until treatment is complete for 7 days.

Nursing Diagnoses:
 Noncompliance
 Knowledge deficit
 Impaired social interaction

C) CHLAMYDIAL INFECTIONS – the most prevalent STD’s and responsible for many GU disorders.

 Etiologic Agent: Chlamydia trachomatis

  Mode of Transmission: Direct, Sexual Contact;
In the New born- direct contact with the mother’s infected tissues.

 Incubation Period: 7 to 21 days

Assessment Findings:

 ASYMPTOMATIC IN MANY CASES- symptoms appear when complications set in and depend
on which part is affected.
= Similar to gonorrhea but less severe.

Female: Friable edematous cervix; yellow, muco-purulent discharges; spotting at menstrual mid
cycle or sexual intercourse.
Complications: Salpingitis, PID and Ectopic pregnancy.

Males: Dysuria; Urethritis; white, clear urethral discharges.

Complications: Epididymitis

Collaborative Care:

1) Laboratory and Diagnostics Tests

 Gram stain and culture
 DFA
 ELISA

2) Pharmacology
 Azithromycin / oral doxycycline
 Ofloxacin
 Erythromycin
* To confirm a cure, a repeat culture 4-7 days after treatment should be done.

Nursing Management:

 Client should be instructed about sexual mode of transmission.

 Increased risk of infection with multiple partners.
 Client should be informed of the serious danger of infertility.
 To complete the entire course of antibiotic treatment.
 To wear condoms for protection and reinfection.

Nursing Diagnoses:

 High risk for infection transmission

 Knowledge Deficit
 High risk for injury (complications)

D) GENITAL WARTS OR VENEREAL WARTS (Vietnam Rose or Condylomata Acuminata)

= consist of papilllomas (a benign epithelial tumors growing outwardly in finger-like fronds.
  Etiology: Human Papilloma Virus – can lead to precancerous changes in the cervix or to cervical
cancer or anal cancer.

 Mode of Transmission: Sexual contact involving the anus, mouth or vagina.

 Incubation Period: Less than two months

Assessment Findings:

1) Tiny red or pink swellings that grow and become pedunculated

2) Multiple swellings giving a cauliflower appearance

Men: Warts may occur on the penis, scrotum, anus and urethra.

Women: Warts may be located on the vulva, vagina, cervix, and perianal area.

 Assess for cervical changes  HPV associated with up to 90% of cervical malignancies.
 Genital warts can also occur: Lips, mouth, tongue and throat.

Collaborative Care:

1) Diagnosis done by clinical appearance

= Biopsy
= Pap smear
2) Pharmacology (Topical wart treatment)
 Podofilox 0.5% (Condylox)
 Podophyllin 10% - 25% drops in Tincture Benzoin compound – a cytotoxic agent carefully
applied to wart area to normal tissue being avoided. Should be washed off in 1-4 hours.

3) Other techniques:

 Cryotherapy – freezing of skin lesions; used to treat variety of benign and malignant
lesions.
 Electrocautery – removes genital wart on the penis, vulva or around the anus by burning
them with a low voltage electrified probe.
 Surgical excision – removing of tissue that contain s the virus

 Careful long-term follow up of the virus is advised.

Nursing Diagnoses:

 Impaired tissue integrity

 Fear
 Anxiety

E) TRICHOMONIASIS- A Protozoan infection of the lower GUT affecting about 15% of sexually active
females and 10% of sexually active males. Frequently carried asymptomatically by the male partner.

 Etiology: Trichomonas vaginalis

 = Alkaline environment (pH 6-7)

 Mode of Transmission: Direct sexual contact; Indirectly by contaminated douche equipment,

moist wash cloth, swimming in contaminated water;
In the newborns- direct contact with mother’s infected tissues

 Incubation Period: 7 - 28 days

Assessment Findings:

a) In females - Vaginal irritation, burning, swelling and itching of external genitalia (vulva), usually
profuse, frothy, foul smelling yellow-green discharges. Occasionally the cervix is covered with
punctuate hemorrhages (strawberry cervix).

b) In males- Mostly asymptomatic- transient mild to severe urethritis, dysuria or urinary frequency.
Collaborative Care:

1) Laboratory and Diagnostic Test

➪ Normal saline wet prep- to detect the presence of protozoa.
= No douching, no lubrication – to avoid destroying the pathogen to yield accurate results.
2) Pharmacology
➪Metronidazole (Flagyl) for the client and sexual partner 2 grams x 1 dose.
 Vaginal Clotrimazole – for pregnant women.

Nursing Management:

 Refrain from sexual intercourse

 Males should wear condoms while infection remains active.
 Good perineal hygiene
 Treatment should be continued through the women’s menstrual period.
 After therapy has completed the client are evaluated and treated if necessary (after 7-10
days of Metronidazole)
= Repeat NS wet prep

Nursing Diagnoses:

 Knowledge Deficit
 Noncompliance
 Altered Comfort- Itching

EMERGING INFECTIONS:

Coronavirus Disease (COVID-19)

 is an infectious disease caused by a newly discovered coronavirus.
  Most people who fall sick with COVID-19 will experience mild to moderate symptoms and
recover without special treatment.

HOW IT SPREADS:

 The virus that causes COVID-19 is mainly transmitted through droplets generated when an
infected person coughs, sneezes, or exhales. These droplets are too heavy to hang in the air,
and quickly fall on floors or surfaces.
 You can be infected by breathing in the virus if you are within close proximity of someone
who has COVID-19, or by touching a contaminated surface and then your eyes, nose or
mouth.

COVID-19 affects different people in different ways. Most infected people will develop mild to
moderate illness and recover without hospitalization.

Most common symptoms:

 Fever
 Dry cough
 Tiredness
Less common symptoms:
 Aches and pains
 Sore throat
 Diarrhea
 Conjunctivitis
 Headache
 Loss of taste or smell
 A rash on skin, or discoloration of fingers or toes

 Protect yourself and others around you by knowing the facts and taking appropriate
precautions. Follow advice provided by your local health authority.

To Prevent the Spread of COVID-19:

 Clean your hands often. Use soap and water, or an alcohol-based hand rub.
 Maintain a safe distance from anyone who is coughing or sneezing.
 Wear a mask when physical distancing is not possible.
 Don’t touch your eyes, nose or mouth.
 Cover your nose and mouth with your bent elbow or a tissue when you cough or sneeze.
 Stay home if you feel unwell.
 If you have a fever, cough and difficulty breathing, seek medical attention.

 Calling in advance allows your healthcare provider to quickly direct you to the right
health facility. This protects you, and prevents the spread of viruses and other
infections.
Masks:
  Masks can help prevent the spread of the virus from the person wearing the mask to others.
Masks alone do not protect against COVID-19, and should be combined with physical
distancing and hand hygiene. Follow the advice provided by your local health authority.

COVID-19: Nursing Management

Based on assessment data, nursing interventions for COVID-19 should focus on monitoring vital
signs, maintaining respiratory function, managing hyperthermia, and reducing transmission.

1. Monitor vital signs – particularly temperature and respiratory rate, as fever and dyspnea are
common symptoms of COVID-19.
2. Monitor O2 saturation – normal O2 saturation as measured with pulse oximeter should be 94
or higher; patients with severe COVID-19 symptoms can develop hypoxia, with values dropping
low enough to warrant supplemental oxygen.
3. Manage fever – use appropriate therapy for hyperthermia, including adjusting room
temperature, eliminating excess clothing and covers, using cooling mattresses, applying cold
packs to major blood vessels, starting or increasing intravenous (IV) fluids as allowed,
administering antipyretic medications as prescribed, and readying oxygen therapy in the event
of respiratory problems resulting from the metabolic demands for oxygen during a fever
4. Maintain respiratory isolation – isolation rooms should be well-marked with limited access; all
who enter the restricted-access room should use personal protective equipment, such as masks
and gowns.
5. Enforce strict hand hygiene – to reduce or prevent transmission of coronavirus, patients
should wash hands after coughing, as should all who enter or leave the room.
6. Provide information – educate the patient and patient’s family members of the transmission
of COVID-19, the tests to diagnose the disease, disease process, possible complications, and
ways to protect oneself and one’s family from coronavirus.

Medical Management – depends on the severity of the condition (Current Guidelines and
Recommendations National Institute of Health (NIH) January 2021) ( www.cdc.gov/
www.who.int )

I. Not Hospitalized – patients with mild symptoms

Rest, drink fluids, take oral over the counter medications to manage fever and nasal congestions.
Isolate ( Including from other household residents)

II. Hospitalized, don’t require supplemental Oxygen

Supportive treatment (decrease symptoms and improve comfort)
-Remdesivir

III. Hospitalized Require- Flow Supplemental Oxygen

Unable to maintain appropriate oxygen saturation should receive oxygen supplementation

IV. Hospitalized, Requires High Flow Supplemental Oxygen

-Dexamethasone or Prednisone + Remdesiver

V. Hospitalized Require Invasive Mechanical Ventilator

-ECMO (Extracorporeal Mechanical Oxygenation)

Other proposed treatments

1. Convalescent plasma – recovered from COVID19 with antibodies – blood plasma for patient
severely ill with COVID19 (FDA – Issued emergency authorization; NIH – not sufficient evidence – not
recommended to routine care)
2. Interleukin – 6 Inhibitors – Sarilumab, Tocilizumab, Siltuximab
Research: block inflammatory pathways – may prevent worsening of COVID19 symptoms (FDA –
approved ; NIH – Recommends against use with insufficient data to support)

Self-care:

 If you feel sick you should rest, drink plenty of fluid, and eat nutritious food. Stay in a
separate room from other family members, and use a dedicated bathroom if possible. Clean
and disinfect frequently touched surfaces.
 Everyone should keep a healthy lifestyle at home. Maintain a healthy diet, sleep, stay active,
and make social contact with loved ones through the phone or internet. Children need extra
love and attention from adults during difficult times. Keep to regular routines and schedules
as much as possible.
 It is normal to feel sad, stressed, or confused during a crisis. Talking to people you trust, such
as friends and family, can help. If you feel overwhelmed, talk to a health worker or
counsellor.

Nursing Diagnoses
 Hyperthermia
 Impaired Gas Exchange
 Fatigue
 Dysfunctional Ventilatory weaning response
 Ineffective airway clearance
 Risk for infection
 Decreased cardiac output
 Risk for shock
 Risk for autonomic Dysreflexia
 Impaired skin integrity

IMMUNOLOGIC REACTIONS:

ACQUIRED IMMUNODEFICIENCY SYNDROME

 - a disease caused by a virus, which impairs the immune function of the individual and
characterized by the progressive weakening of the T cell-mediated immunity making the
individual susceptible to certain opportunistic infections and malignancy.

➣ Etiology: HIV

➪ It a retrovirus (carries genetic code in its RNA), belonging to the lentivirus (slow growing)
group.
➪ Spread through the blood, semen, vaginal secretions and breast milk.
➪ It cannot survive long outside the body’s fluids or tissues and cannot penetrate unbroken
skin.

➣ Mode of Transmission: Sexual Contact; Exposure to infected Blood or Blood Products; Perinatal
transmission.

➣ Incubation Period: 6 months to 7 yrs. or more

Pathophysiology:

 HIV virus enters body  Virus invades cells (Helper T cells) which have the CD4 antigen 
Once inside cell virus sheds protein coat  Viral RNA converted to viral DNA (through the
enzyme Reverse transcriptase)  Viral DNA integrates with the host cell DNA and duplicated
during the normal processes of cell division  Within the cell, the virus may become latent or
become activated to produce new RNA and form new virions causes lysis of host cells as virus
seeks to invade other cells  destroying T-Helper cells of the body over time.

Epidemiology:

➣Origin- Unknown

➣1980- first report of the disease in US

 Research indicated that HIV/AIDS already present in different parts of the world 30 – 40 years
before the 80s, only spreading rapidly in 1980 due to increasing global travel and migration

➣ 1983- the word AIDS was coined

➣ 1984- first report of HIV/AIDS in the Philippines (2 cases AIDS)

➣ GLOBAL AIDS- The AIDS epidemic- the most devastating health disaster in human history
 By the end of 2005, in addition to the 25 million people who have died with AIDS, at least 40
million people are now living with HIV
➣ An estimated 4.9 million people were newly infected with HIV in 2005 – 95 % of them were in
sub-Saharan Africa, Eastern Europe, or Asia (China and India).
➣ Globally, the AIDS pandemic shows no sign of slowing, despite concerted efforts to control it. The
difficulty in reducing the number of new infections is also compounded by poor access to
lifesaving treatment.

➪ AIDS has exacted a devastating toll on population and health over the last 25 years. The
number of people living with HIV has surged from a few thousand in the 1980s to 40 million in
2005, and has spread to all world regions.
 NATURAL HISTORY OF HIV INFECTION

HIV INFECTION
(Successful Entry of the virus; An individual becomes infected / infectious)


ACUTE SEROCONVERSION ILLNESS
(With 3 – 8 weeks individuals develop an acute illness, lasting 2–3 weeks with symptoms such as
fevers, rash, joint and muscle pain, swollen lymph glands, diarrhea and sore throat)

ASYMPTOMATIC INFECTION
(Individual may remain asymptomatic and feel and appear for healthy for 5 – 10 years; yet remains
infectious; blood is positive for HIV antibodies; some have PGL)


EARLY SYMPTOMATIC ILLNESS
(Many individuals develop constitutional s/s referred as AIDS- related Complex [ARC], such as oral
thrush, diarrhea, weight loss, low-grade intermittent fevers and night sweats, a variety of skin rashes,
etc. various fungal and viral infections will be seen and individuals feel chronically ill during his stage.)

LATE SYMPTOMATIC ILLNESS, i.e. AIDS

(Episodes of AIDS specific opportunistic diseases such as PCP, encephalitis caused by Toxoplasma
gondii; and Severe and chronic diarrhea caused by cryptosporidia and microsporidia; PTB;
opportunistic cancer such as Kaposi sarcoma and undifferentiated B cell lymphomas; significant
weight loss; both neurologic and neuropsychiatric syndromes may be present.)


TERMINAL PHASE  DEATH
 HIV progresses over a decade before developing into AIDS, but there is a long delay after infection
before symptoms becomes evident.

Collaborative Care:
➪ Goals of Care for client with HIV
▪ Early identification of the infection
▪ Promoting health maintenance possible as long activities to prolong the asymptomatic period
▪ Prevention of Opportunistic infections
▪ Treatment of disease complications, such as cancers
▪ Providing emotional and psychosocial support

➪ Prevention
▪ Education
▪ Counseling
▪ Behavior Modification

Diagnostic Tests:

a) HIV antibody tests, such as-

 Screening Test- ELISA, Agglutination Tests – a blood test used to identify unknown antigen.
  Confirmatory Test- Western Blot – a very specific method used in the testing of HIV
antibodies
in the blood.
b) Antigen test- Hivagen Test – used to confirm positive results from the other available tests.
c) HIV culture test – used to detect the presence of HIV in serum, saliva or urine. The test may
detect HIV antibodies, antigen or RNA.
d) T- cell assay or Immune Profile Test – to monitor the progress of disease and guide therapy
e) HIV viral load test – measures the amount of activity replicating the HIV virus
f) CBC
g) Tuberculin testing – to see if the client has been exposed to TB.
h) MRI – detecting structural abnormalities.
i) Specific cultures and serology examinations for opportunistic infections
j) Pap smear – method of cervical screening.

CONVENTIONAL TESTING ALGORITHM

ELISA SCREEN

(-) (+ or I)
Report Results Repeat ELISA

(-) (+ or I)
Report Results Western Blot

Report Results

Pharmacology: (Antiviral Therapy)

 Current HAART (High Active Antiretroviral Therapy) options – are combinations (or
cocktails) consisting of 33 medications belonging to at least 2 types or “classes” of
antiretroviral agents.
 Initial Treatment: Typically, a NNRTI plus 2 NRTI (AZT and Lamivudine)
= Combinations of agents may include a protease inhibitor (PI), are used if the above
regimen loses effectiveness.

a) Nucleoside Analogs (NRTIs – Nucleoside Reverse Transcriptase Inhibitors) – prevent viral

Replication (spread) for HIV (+).

▪ Zidovudine (Retrovir, AZT)

▪ Didanosine (ddl, Dideoxyinosine)
▪ Zalcitabine
▪ Stavudine
▪ Lamivudine (3TC)
 b) Protease Inhibitors (PI) – block protease (essential for virus maturation) activity.

▪ Saquinavir (Invirase)
▪ Ritonavir (Novir)
▪ Indinavir (Crixivan)
▪ Nalfinavir (Veracept)

c) Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) – prevents transfer of info that

would allow the virus to replicate or survive.
▪ Nevirapine (Viramune)
▪ Delavirdine

 Benefits of treatment include a decrease risk of progression to AIDS and a decreased risk of
death.
 It also improves physical and mental health.
 With treatment there is a 70% reduced risk of acquiring Tuberculosis.

 Vaccination: As of 2012, there is no effective vaccine for HIV or AIDS.

= A single trial of the vaccine RV 144 published in 2009 found a partial reduction in the risk of
transmission of roughly 30%, stimulating some hope in the research community in developing a
truly effective vaccine. Further trials od RV144 vaccine are ongoing.

Implementation:
= more on symptomatic management (Treat signs and symptoms).

 Maintain nutritional status – increase caloric diet

 Provide oxygen and maintain pulmonary function – O2 administration, suctioning of secretions,
ABG monitoring.
 Provide comfort measures for fatigue – proper positioning, provide rest periods.
 Provide skin care – apply emollient lotion, keep skin dry and clean.
 Provide supportive care for elevated temperature – TSB; antipyretic as indicated.
 Administer appropriate care for diarrhea – Sandostatin; MIO; fluid replacement as indicated.
 Provide measures to reduce pain – proper positioning; Analgesic.
 Monitor client to prevent injuries – provide safety measures.
 Mycobacterium Avium Complex (MAC) infection – Azithromycin (Zithromax), Clarithromycin
(Bioxin) as indicated.
 Pneumocytis Carinii Pneumonia (PCP) – Temozolomide (TMZ)/Sulfamethazine (SMZ) as
indicated.
 Eye infection – Valganciclovir; handwashing.

Education:

 Abstinence – sex
 Protection (condom)
 Monogamous partner
 Assessing partner before sex

Nursing Diagnoses:

 Ineffective Individual Coping

 Impaired Skin Integrity
 Altered Nutrition Less than Body Requirements
 Altered Sexuality Pattern
 Activity Intolerance
 Powerlessness

HYPERSENSITIVITY REACTIONS:

 Hypersensitivity or allergy – is an increased or excessive response to the presence of an antigen

(foreign protein or allergen) to which the patient has been previously exposed.
 Causes problems that range from uncomfortable (ex., itchy, watery eyes or sneezing) to life
threatening (ex., allergic asthma, anaphylaxis, bronchoconstriction, or circulatory collapse).

ANAPHYLAXIS

 The most dramatic and life-threatening example of a type 1 hypersensitivity reaction, occurs
rapidly and systematically.
 It affects many organs within seconds to minutes after allergen exposure.
 Anaphylaxis is not common, and the episodes vary in severity but can be fatal.

Common Agents That Cause Anaphylaxis:

Drugs/Foreign Proteins:

 Antibiotics (penicillin, cephalosporin, tetracycline, sulfonamides, streptomycin, vancomycin,

chloramphenicol, amphotericin B).
 Adrenocorticotropic hormone, insulin, vasopressin, protamine.
 Allergen extracts, muscle relaxants, hydrocortisone, vaccines, local anesthetics (lidocaine,
procaine).
 Whole blood, cryoprecipitate, immune serum globulin
 Radiocontrast media
 Opiates

Foods:

 Shellfish, eggs, legumes, nuts, grains, berries, preservatives, bananas and peanuts

Other Agents:

 Pollens, exercise, heat/cold, latex

Insects/Animals:

 Hymenoptera: bees, wasp, hornets

 Fire ants
 Snake venom

Clinical Manifestations:
  A patient having an anaphylactic reaction, first has feelings of uneasiness, apprehension,
weakness and impending doom.
 Become anxious and frightened.
 These feelings are followed quickly by generalized itching and urticaria (hives).

Mild: Related to mucosal edema

 2 – 4 hours
 Peripheral tingling – numbness
 Sensation of warmth
 Fullness of mouth and throat
 Nasal congestion
 Periorbital swelling

Moderate:

 Begins in 2 hours
 Flushing Due to inflammation.
 Warmth
 Anxiety – due to decrease O2 level.
 Itching – due to allergy.
 Serious reactions: Bronchospasm  airway edema, dyspnea, cough, wheezing.

Severe:

 Abrupt onset
 Laryngeal edema as “a lump in the throat”, hoarseness and stridor (a crowing sound)
 Severe dyspnea, cyanosis – decrease oxygen.
 Dysphagia, diarrhea, abdominal cramping – due to GI swelling.
 FVD = hypotension – due to vasodilation and extensive capillary leak.
 Decrease oxygen level
 Seizures  Cardiac arrest  Coma  Death caused by respiratory failure or by shock or cardiac
dysrhythmias.

Medical Management:

 Epinephrine 1:1000 solution, SQ – given as soon as symptoms of systemic anaphylaxis occur 

vasoconstriction.
 Antihistamines such as diphenhydramine (Benadryl), given IV, IM or orally – to treat urticaria.
 Increase oxygen concentration – to prevent cardiac arrest and reduce hypoxemia.
 FVD: IV infusion (NS), volume expanders (LR)
 Vasopressor agents – to increase BP such as Dopamine/Dobutamine.
 Aminophylline /Theophylline – for severe bronchospasm.
 Corticosteroids – to reduce swelling and inflammation.

Nursing Interventions:
 Check ABC – to assess respiratory function first. For cardiac arrest.
 Avoidance to exposure to antigens
 Notification of physician for emergency measures.
 Monitor signs and symptoms of increase edema and respiratory distress.