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COMMUNICABLE DISEASES

Special Class

COMMUNICABLE DISEASES
DEFINITION An infectious disease is a clinically evident illness resulting from the presence of pathogenic microbial agents, viruses, bacteria, fungi, including pathogenic viruses, pathogenic bacteria, fungi, protozoa, protozoa, multicellular parasites, and aberrant proteins parasites,

 Definition pathogens are able to cause disease in animals and/or


plants . Infectious pathologies are also called communicable diseases or transmissible diseases due to their potential of transmission from one person or species to another by a replicating agent (as opposed to a toxin

I. INFECTION CONTROL
        Barriers to Infection: 1st Barrier Integrity of the Skin 2nd Barrier Immunity, Anti-Oxidant and Vaccines Anti3rd Barrier Inflammatory Process (Metabolic Energy, Phagocytes & Clotting System) Infection Control: Dose x Virulence Host Resistance (2003 Smith Duel Martin American Association of Infection Control, DOH Handbook 2002)

1.CONDITIONS PREDISPOSING INFECTION


1. Surgical wounds 2. Antibacterial Immune Mechanisms 3. Alterations In the Respiratory Tract 4. Alterations in the Genitourinary Tract 5. Nosocomial Septicemias in Invasive Devices a. Venipuncture Sites (IV related septicemias) b. TPN (Total Parenteral Nutrition) c. Implanted Prosthetic Devices (artificial cardiac valves, CSF monitoring devices CVP, vascular grafts)

2.LATEST STANDARD PRECAUTION


Procedure Hand Washing Yes Gloving Gown Mask Goggles No Taking the vital signs without touching Mucus membranes, Blood, Body fluids Taking V/S Touching Mucus Membranes, Blood, Body fluids Drawing Blood & Inserting Venous Access Suctioning, Intubations, Handling soiled waste linen, Inserting Arterial Access, Endoscopy Operative with extensive SPLATTERING of Blood or bloody fluids Yes Yes No No No No No No

Yes Yes

Yes Yes

Yes Yes

Yes Yes

No Yes

Protective eyewear should be worn at all times when the nurse is drawing cord blood.

3.RECOMMENDATION FOR TRANSMISSION BASE PRECAUTION


Transmission Contact Droplet Airborne

Disease Example:

Diphtheria Herpes simplex, Scabies, Staphylococcus, Hepa A, Respiratory Syncytial Virus & Skin Infections

Diphtheria Strepto Pneumonia Scarlet Fever Meningitis Rubella

Diphtheria Varicella PTB Measles

Room Placement

All Private Rooms. Place the patient in a room with the same Diagnosis

Respiratory Protection:

Mask not necessary

Use mask within 3 feet

With mask

Types of Isolation 1. Strict Isolation:

Indications  Highly transmissible diseases by direct contact and airborne routes of transmission

Requirement Private room Gowns, mask, gloves Double bagged techniques for soiled articles Private room Patients with the same organism generally may share a room Private room with negative pressure ventilation so the room air is vented to the outside. outside. Mask Hand washing Bronchoscopy and dental examination generally are postponed until the patient has received approximately 2 weeks of appropriate anti tuberculosis therapy

2. Respiratory Isolation:

Droplet transmission

3. Tuberculosis/ AFB Isolation:

Suspected/active TB

4. Contact Isolation:

Infectious diseases or multiple resistant microorganisms that are spread by close or direct contact. Infectious diseases transmitted through direct or indirect contact with infected feces Patients with wound drainage/infected wounds

Private room Mask, gown, gloves

5. Enteric Precautions:

Private room is required if patient does not practice good hygiene measures

6. Drainage / Secretions Precautions:

Gloves Gowns are indicated if clothing is likely to be contaminated

7. Universal Blood and Body Blood-borne, body fluids BloodFluids Precautions: pathogens (blood, semen, vaginal secretions, CSF, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid and tissues)

Gloves Masks and protective eye gears Gown Contaminated needles should not be recapped Use puncture resistant containers for used needles and other sharp items

Strict Isolation

Respiratory Isolation

Contact Isolation

Diphtheria, Pharyngeal Infection Herpes zoster Pneumonia S. aureus Varicella (chickenpox) Streptococcus,

H. influenza Measles Mumps

Diphtheria, cutaneous Herpes, simple Pediculosis Scabies Syphilis

N. meningitis

 Group A

Enteric Precaution

Blood and Body Fluids Precautions

Tuberculosis/AFB Isolation

Aseptic meningitis Infectious Diarrhea Gastroenteritis: Clostridium defficile Giardia lamblia Rotavirus Salmonella Hepatitis A Typhoid fever

AIDS Hepatitis B Hepatitis C

 Tuberculosis

II. IMMUNIZATION

Note: Natural Passive Immunity: IgA thru placental transfer Natural Active Immunity: recovery from a viral illness Artificial Passive Immunity: Diphtheria Anti-toxin Artificial Active Immunity: Toxoids & Live attenuated weakened Vaccine

Hepatitis B vaccine
1. The vaccine protects against hepatitis B. 2. The first dose of hepatitis B should b administered soon after birth and before hospital. 3. Vaccine is administered intramuscularly in the vastus lateralis muscle in newborns and in the deltoid for older infants and children (dorso(dorso-gluteal site is avoided).

4. Anaphylactic reaction to common bakers yeast is a contraindication. - Infant should be tested for HBsAg and antibody to hepatitis B surface antigen at 9 to 15 months of age. 5. Mother whose HBsAg status is unknown a. Infant should receive the first dose of hepatitis vaccine series within 12 hours of birth. b. Maternal blood should be drawn as soon as possible to determine the mothers HBsAg status. c. If the HBsAg test is positive, the infant should receive hepatitis B immune globulin as soon as possible (no later than age 1 week). d. The second dose of hepatitis B vaccine is recommended at age 1 to 2 months. e. The last dose hepatitis B vaccine should not be administered before age 6 months

Haemophilus Influenzae type b (Hib) conjugate vaccine


1. The vaccine protects against a number of serious infections caused by H. influenzae type b, such as bacterial meningitis, epiglottitis, bacterial pneumonia, septic arthritis, and sepsis. 2. The Hib is administered at 2 months, 4 months, 6 months, and between 12 and 15 months of age.

3. Depending on the brand of Hib vaccine used for the first and second doses, a dose at 6 months of age may not be needed. 4. The Dtap/Hib combination products should not be used for primary immunization in infants ages 2, 4, or 6 months but can be used as boosters following any Hib vaccine. 5. The Hib vaccine are administered by intramuscular injection and are given at a separate site from any concurrent vaccinations.

6. Vaccine recommended annually for children from age 6 months with certain risk factors such as asthma, sickle cell disease, human immunodeficiency virus infection, diabetes mellitus, and household members of persons in groups at high risks. 7. Annual vaccinations are recommended for adult groups at high risk. a. Anyone 50 years of age or older

b. Adults of any age with a chronic cardiac or pulmonary disease c. Residents of long-term care facilities longd. Immunocompromised adults e. Women who will be in the second or third trimester of pregnancy during influenza season 8. Administered vaccine by intramuscular injection. 9. Vaccination is contraindicated in person with anaphylactic hypersensitivity to eggs.

Measles, mumps rubella vaccine (MMR)


1. The MMR protects against measles, mumps, and rubella (German measles). 2. The first dose of MMR is administered between 12 and 15 months of age; the second dose is administered at 4 to 6 years of age (the second dose may not be administered during any visit as long as at least 4 weeks have elapsed since the first dose and both doses are administered beginning at or after age 12 months)

3. If the second dose was not given by 4 to 6 years of age, it should be given at the next scheduled pediatrician or health care clinic visit. 4. Those who have not received the second dose previously should complete the schedule at the 11 to 12 year-old pediatric or health care clinic visit. year5. The MMR contains minute amounts of neomycin ; measles and mumps vaccines, which are grown on click embryo tissue cultures, are not believed to contain significant amounts of egg cross-reacting crossproteins.

6. Contraindication a. Pregnancy b. Known altered immunodeficiency c. Allergy to contents of immunization (before the administration of MMR vaccine, assess for a known history of allergy to neomycin or related antibiotics). d. Presence of recently acquired passive immunity through blood transfusions, immunoglobulin, or maternal antibodies (MMR should be postponed for a minimum 3 months after passive immunization with immunoglobulins or blood transfusions, except washed blood cells, which do not interfere with the immune response).

Pneumococcal vaccine
1. A heptavalent pneumococcal conjugate vaccine is recommended for all children ages 2 to 23 years months 2. The vaccine can be given concurrently with other childhood vaccines at 2, 4, 6, and 12 to 15 months of age. 3. It is recommended for certain children age 24 to 59 months.

4. Vaccine is recommended for persons 65 years of age or older and those with chronic cardiovascular diseases, chronic pulmonary disease or diabetes mellitus. 5. Revaccination is advised if the individual was less than 65 years of age at the time of vaccination. 6. In immunocompromised persons, an initial vaccination is recommended, followed by revaccination every 5 years.

1. Legionnaires Disease
Causative Agent Type of Agent Mode of Transmission Incidence Legionella pneumophilia Gram-negative bacillus GramAirborne route Occurs more often in men than in women Middle-aged and elderly Middlepeople Peak incidence in persons over 50 who are cigarette smokers.

Predisposing factor

Immunosupression Underlying disease such as diabetes, chronic renal failure, or COPD Cigarette smokers (3-4 (3times more to develop than nonnon-smokers) High fever, chills, cough, chest pain, tachypnea, diarrhea, anorexia, diffuse myalgias, grayish, nonpurulent, & occasionally bloodblood-streaked sputum

Signs & symptoms

Nausea, vomiting, pleuretic chest pain, disorientation, mental sluggishness, fine crackles, & in 50% of patients bradycardia. Hypotension, delirium, heart failure, arrhythmias, renal failure, shock (usually fatal)

Late sign/Complication

Respiratory Failure

Dx Test Confirmative/Definitive

#1 Drug of Choice

Direct immunofluorescence of respiratory tract secretions & tissue culture of L. pneumophilia Erythromycin or newer macrolide antibiotic such as clarithromycin Blurred vision, itching, urticaria,

Drug A/R

Nursing Consideration

Watch for restlessness as a sign of hypoxia which requires suctioning, repositioning, or aggressive oxygen therapy Watch for signs of shock Teach patient how to cough effectively, and encourage deep breathing exercises Teach patent to watch signs for sensitivity (itching, redness, swelling)

2. Vancomycin-resistant Enterococcus (VRE) VancomycinCausative Agent Type of Agent Mode of Transmission Enteroccoci Gram-positive microbes GramDirect contact between patient and caregiver  patient contact with contaminated surfaces Elderly patients

Incidence

Predisposing Factors

immunosuppression
pt with hx of taking vancomycin, third generation cephalosporins Pts with indwelling urinary or central venous catheters prolonged hospitalization Pts with malignancies or chronic renal failure Pts with wounds with an opening to the pelvic or intraintraabdominal area Pts exposed to exposed contaminated equipment or to VREVRE-positive patient

Signs & symptoms

No specific s/s

Diagnostic test

Colonization through rectal swab or stool

# 1 Drug of Choice S/E

Synercid & Zyvox Headache, nausea, diarrhea, vomiting, arthralgia, myalgia, rash, pruritus thrombophlebitis, infusion site reaction

A/D

Nursing Consideration

Frequent handwashing before and after care of patient Maintain contact precaution when caring the patient Place patient in private room with personal equipment for patient only Instruct patient to immediately report irritation at the IV site

Monitor liver function test during the therapy Instruct patient to take antibiotics for full prescription period, even if they begin to feel better Monitor for s/s of super infection and ensure judicious and careful use of antibiotics

3. Erythema Infectiosum (Fifth Disease)


Causative Agent Type of Agent Mode of Transmission Human parvovirus B19 (HIV) Virus Unknown, possibly respiratory secretions and blood School-aged children School(4-12 yrs old) (4None

Incidence Predisposing factor

Initial Sign

Red rash on cheeks (page 229 of Gapuz) Stages of the Rash: Erythema of the face (slapped face appearance), chiefly on the cheeks; disappears by 1 to 4 days Approximately 1 day after the rash appears on the face, maculopapular red spots appear, symmetrically distributed in the extremities, rash progresses from proximal to distal surfaces and may last a week or more

Rash subsides but may reappear if the skin becomes irritated or traumatized by such factors as the sun, heat cold, or friction
(Saunders, page 478)

Late Sign

Myalgia Lethargy Nausea Vomiting Abdominal pain


(Saunders, page 478)

Cardinal sign Screening test

Not seen IgM antibody test Polymerase chain reaction detection test (Lippincotts Manual of Nursing Practice 6th ed., page 1124) Not seen

Confirmative test

Drug of Choice Nursing Consideration

None Provide frequent rest periods Increase iron in the diet

Instruct the patient to cover the mouth when coughing or sneezing Respiratory isolation of the hospitalized child Pregnant women should not be in contact with or care for the infected person Supportive care Administer antipyretic, analgesics, and antiantiinflammatory medications as prescribed.

4. Acute Glomerulonephritis Vs. Nephrotic Syndrome


Factor Nephrotic Syndrome Acute Poststreptococcal Glomerulonephritis (APSGN) chronic Acute

Illness type

Illness course

Characterized by periods of exacerbations and remissions during many years

Predictable, selfselflimiting, typically lasting 4-10 days 4(acute edematous phase)

Cause

unknown

Group A -hemolytic streptococci

Age of onset

2-4 yrs

Early school-age schoolchildren, peaks at 667 yrs old More common among boys

Sex

More common among boys

treatment

Symptomatic-no Symptomaticknown cure; prednisone, cyclophosphamide, furosemide

Penicillin (EES), hydralazine, furosemide

Major signs and symptoms: General

Blood pressure Edema

Hematuria, Syndrome with hypertension variable pathology: massive proteinuria, hypoalbuminemia, severe edema, hyperlipidemia Normal or decreased Elevated Generalized or severe Periorbital or peripheral

Proteinuria Serum protein level Serum lipid level Potassium level

Massive Decreased (1.6-7.9 (1.6g/dL) Elevated Normal ( 3.5-5 3.5mEq/L)

Moderate Increased Normal Increased

Fluid restrictions

Seldom necessary

Necessary if output is significantly reduced

Specific Nursing Care

Treat at home if possible, good skin care, prevent infection

Treat in hospital during acute phase; monitor vital signs, especially blood pressure; on discharge, stress need to restrict activity until microscopic hematuria is gone

Diagnostic test

Urinalysis

Urinalysis

24 hour urine for Blood protein Needle biopsy of Needle biopsy of the kidney kidney Serum chemistry

5. Meningitis
Causative Agent Type of Agent Mode of Transmission N. meningitidis Bacteria Direct contact with droplets from respiratory passages

Incidence

Prognosis is worse on infants and elderly

Predisposing factor

Skull fracture, penetrating head wound, lumbar puncture, ventricular shunting, sinus or upper respiratory tract infection, use of nasal sprays, individuals with compromised system Fever, chills, malaise Increased ICP, confusion, petechial rash, photophobia, nuchal rigidity, (+) Kernigs & Brudzinskis sign, deep stupor, and come Lumbar Puncture and (+) Kernigs & Brudzinskis sign

Initial signs Other signs

Confirmative Test

Drug of Choice

Large dose Iv antibiotics such as penicillin G, ampicillin, ceftriazone, cefotaxime

S/E

Dizziness, depression, fatigue, n&v, hypersensitivity rxn, pain at insertion site

A/R Leukopenia, agranulocytosis, thrombocytopenia, arthralgia, anaphylaxis

Nursing Consideration

Administer antibiotics on time and antipyretics Administer cooling measures Monitor IV fluid flow to prevent increased ICP Maintain quiet and calm environment Monitor I&O closely Avoid giving narcotics which may mask a a decreasing LOC, seizure, or altered respirations Initiate safety precautions Darken room if photophobia is present Advise close contacts that prophylactic antibiotic may be indicated

6. KAWASAKI disease Causative agent Mode of Transmission Incidence Unknown Unknown 80% occurs in children under age 5 Unknown (autoimmune in nature)
Fever that is high grade

Predisposing factor
Initial Sign:

(greater than 102 degrees Fahrenheit and often 104 degrees) and remains elevated more than three days (persistent fever lasting at least five days is considered a hallmark sign). Fever that is unresponsive to feverfever-reducing medications or ibuprofen Cardinal Sign Strawberry tongue white coating on the tongue or prominent red bumps (papillae) on the back of the tongue

Late Manifestations

Extremely bloodshot or red eyes (conjunctivitis without pus or drainage) Bright red, chapped, or cracked lips Red mucous membranes in the mouth Red palms of the hands and the soles of the feet Swollen hands and feet Peeling palms and soles (later in the illness); peeling may begin around the nails Rashes similar to erythema multiforme (rash, NOT blister-like, on blisterthe trunk) Swollen lymph nodes (frequently only one lymph node is swollen), particularly in the neck area. Joint pain (arthralgia) and swelling, frequently symmetrical

Screening Test

CBC ESR Electrocardiogram Chest x-ray xUrinalysis May show pus in the urine (pyuria) May show protein in the urine (proteinuria)

Confirmative Test

Echocardiogram

Complications

Complications involving the heart, including coronary vasculitis and coronary aneurysm, can cause acute myocardial infarction later in life or at a young age.

Nursing Consideration

Monitor temperature frequently. Assess heart sounds and rhythm. Assess extremities for edema, redness and desquamation. Examine eyes for conjunctivitis. Monitor mucous membrane for inflammmation

Monitor dietary and fluid intake (I&O). Administer soft foods and liquids that are neither too hot nor too cold. Weigh daily. Provide passive range-of-motion exercises to facilitate range-ofjoint movement. Administer acetyl salicylic acid (aspirin) as prescribed for its antipyretic and antiplatelet effect. Administer IV immune globulin (IVIg) as prescribed; reduces the duration of fever and the incidence of coronary artery lesions and aneurysms. Instruct the parents in the administration of prescribed medications, the need to monitor for cardiac complications.

Drug of Choice

Immune Globulin IV Nature of the Drug: Immunoglobulin G antibody product. Anaphylactic reactions Chills, fever, erythema, pruritic skin eruptions. Thrombocytopenia, Leukopenia, serum sickness. Anaphylactic reaction.
(PDR Nurses Handbook 1999 ed. & MIMS Drug Handbook 2003)

Side Effects: Adverse Effects:

Discharge Teachings

Immunoglobulin helps to prevent and/or reduce intensity of various infectious diseases. With thrombocytopenia, expect increased platelets and enhanced clotting. OnceOnce-monthly therapy is needed to maintain appropriate IgG serum levels. Drug may cause N&V, fever, chills, flushing, lightheadedness, and tightness in the chest; report immediately, may be dosage and rate related. Close observation and frequent lab studies are essential with pregnant individuals to improve chances of a healthy baby and to ensure maternal safety. Warm soaks to injection site and PO Tylenol may assist to relieve discomfort.
(PDR Nurses Handbook 1999 ed. & MIMS Drug Handbook 2003)

7. Infectious Mononucleosis
Causative Agent Type of Agent Epstein-Barr Virus EpsteinVirus (member of the herpes group) OralOral-pharyngeal route (kissing); blood transfusion Young adults and children (3 & 5 yrs); common in US, Canada, & Europe

Mode of Transmission Incidence

Predisposing factor Initial signs

Not given Fatigue, headache, malaise, and myalgias Triad symptoms: Sore throat, cervical lymphadenopathy, & temperature fluctuations, with an evening peak of 1010 to 1020F.

Cardinal signs

Other s/s

Maculopapular rash, splenomegaly, jaundice, hepatomegaly, stomatitis, exudative tonsillitis or pharyngitis

Complications (rare)

Splenic rupture, aseptic meningitis, encephalitis, hemolytic anemia, idiopathic thrombocytopenic purpura, Guillain- Barr Guillain- Barr syndrome

Diagnostic test

The diagnosis is based on 3 criteria: physical assessment laboratory test (leukocyte count increase) test specific for EBV antibodies Directed at control of manifestations NSAIDS are used to treat fever, avoid Aspirin because of risk of Reyes syndrome Provide cold sponge bath and large fluid intake

Treatment

Nursing Consideration

Bed rest until fever resolve Encourage warm saline throat irrigation to relive sore throat Instruct to avoid contact sports to reduce the risk of splenic rupture Encourage to drink milk shakes, fruit juices, and broths, and to eat cool, bland foods A 5-day course of corticosteroids may be prescribed to 5reduce swelling and has been reported to decrease the

8. Impetigo

Causative Agent

Staphylococcus Aureus and less commonly group A beta hemolytic streptococci

Type of Agent

Bacterial infection

Mode of Transmission

Close contact person to contact person via hands Small macules that rapidly develop into vesicles.

Initial Sign:

Cardinal Sign:

The small macules become pustular and encrusted; causing pain, surrounding erythema; regional adenitis, cellulitis; Itchy. Lesions that commonly affect the face, heal slowly, and leave depigmented areas.

Late Manifestation:

Screening Test:

Gram staining of vesicle fluid. Culture and sensitivity testing of fluid or denuded skin.

Confirmative Test:

Treatment

Topical antibacterial such as Bacitracin or Bactroban

S/E

Nausea, vomiting, urticaria, rash, injection site pain Ototoxicity nephrotoxicity

A/E

Nursing considerations

Contact isolation; use standard (universal) precautions and implement agencyagencyspecific isolation procedures for the hospitalized child. Allow lesions to dry by air exposure. Assist the patient with daily bathing with antibacterial soap, such as pHisoHex, as prescribed. Apply warm compresses to lesions 2 or 3 times per day, as prescribed, to remove crusts and to allow for healing.

Apply and instruct the parents in the use of antibiotic ointments; the infection is communicable for 48 hours after antibiotic ointment treatment is begun. begun. Administer oral antibiotics, which may be prescribed if there is no response to topical antibiotic treatment. Apply and instruct the parents in the use of emollients, as emollients, prescribed to prevent skin cracking. cracking. Instruct the parents in the methods to prevent the spread of the infection, especially careful handwashing. Inform the parents that the child needs to use separate towels, linens and dishes. dishes. Inform the parents that all linens and clothing should be washed separately with detergent in hot water.

9. Scarlet Fever Causative Agent Group A beta-hemolytic betastreptococcal bacteria Streprococcal strain bacteria Inhalation or direct contact / Airborne respiratory particles Children ages 5-15 5-

Type of Agent

Mode of Transmission

Incidence

Predisposing factor

Overcrowded situations (schools, hospitals, child care setting) Low socio-economic status socioEnanthema: tonsils enlarged, edematous, reddened, and covered with patches of exudates Red strawberry tongue Pastia sign (+) blanching test (Schultz-Charlton) (SchultzExanthema: rash within 12 hrs; red pinheadpinhead-sized punctate lesions rapidly becoming generalized but absent in face, desquamation by the end of first week (fine sandpapersandpaper-like on torso; sheetlike sloughing on palms and toes)

Initial sign

Cardinal sign

Other s/s

Prodromal stage: abrupt high fever, pulse increased out of proportion to fever, vomiting, headache, chills, malaise, abdominal pain, coryza, sore throat, cough, and lymphadenopathy

Complications (rare)

Otitis media, peritonsillar abscess, sinusitis, glomerulonephritis, carditis, polyarthritis (uncommon)

Diagnostic Test Definitive Test

 Nose or throat culture

Drug of Choice S/E

Penicillin or erythromycin itching, urticaria, hypersensitivity

Nursing Considerations

Stress the importance of prompt and complete antibiotic therapy Dispose properly all purulent discharges Offer comfort measures, such as Acetaminophen or ibuprofen to relive pain and reduce fever Encourage soothing gargles to relive sore throat pain Encourage liquid diet including warm soups and cool fluids for patients who are having difficulty swallowing Warn patient for experiencing generalized exfoliation over the course for the next 2 to 6 weeks Review warning signs and symptoms secondary to scarlet fever (increased throat or sinus pain, generalized swelling)

10. Clostridium defficile


Causative Agent Type of Agent Clostridium defficile gram-positive anaerobic grambacterium Oral-fecal route/ Enteric OralAntibiotic or antineoplastic therapy, immunosuppression, overdose of Clindamycin

Mode of Transmission Predisposing Factor

Signs & symptoms

The patient may be asymptomatic, or may present any of the following symptoms: soft, unformed stool or watery diarrhea (more than 3 evacuations in 24 hours) that may be foul-smelling or grossly bloody; foulabdominal pain, cramping, or tenderness; and fever. The while blood cell count may be elevated to 20,000/L. In severe cases, toxic megacolon, colonic perforation, and peritonitis may develop.

Incidence

65 years of age and older and hospitalized patients

Diagnostic Test Screening test

Stool culture: most sensitive, with 2-day turnaround. 2NontoxinNontoxin-producing strains of C. difficile can be easily identified using 3 separate stool samples to test for the presence of the toxin. Cell cytotoxin test -highly sensitive and specific for toxins A and B of C. defficile

Confirmative Test

Treatment

For more severe cases, metronidazole 250 mg by mouth (P.O.) four times daily for 10 days is effective therapies, with metronidazole being the preferred treatment. Retesting for C. difficile is unnecessary if symptoms resolve. resolve. Complications include electrolyte abnormalities, hypovohypovo-lemic shock, anasarca (caused by hypoalbuminemia), sepsis, and hemorrhage. Rarely, death may result.

Complications:

Nursing Considerations

Patients with known or suspect C. difficile diarrhea who are unable to practice good hygiene should be placed in a single room or with other patients with the same infection and no other infections. Follow standard precautions and contact precautions for contact with blood and body fluids for all direct patient contact and contact with the patients immediate environment. Use good hand-washing technique with handantiseptic soap. Reusable equipment must be disinfected before use on another patient.

Patients who are asymptomatic, without diarrhea or fecal incontinence for 72 hours, and who are able to practice good hygiene may be transferred out of single rooms. Preventive strategies include careful selection of antibiotic therapy, use of single antibiotics when possible, and avoiding antibiotics when theyre not absolutely necessary, and limiting the duration of the antibiotic treatment regimen. Because spores of C. difficile are resistant to most commonly used stool disinfectants, the patients room may be contaminated even after the patient is discharged. The immediate environment must be thoroughly cleaned and disinfected with 0.5% sodium hypochlorite.

11. BRONCHIOLITIS
Causative Agent Respiratory Syncytial Virus (RSV) A subgroup of the myxoviruses resembling paramyxovirus Highly communicable and is usually transferred by the hands/ Contact precautions children younger than 24 months of age

Type of Agent

Mode of Transmission

Incidence

Symptoms

Initial: Apnea 2nd sign: Paroxysmal and nonnonproductive cough December and January especially when there is unusually high incidence of bronchiolitis or pneumonia are seen in pediatric population.

Temporal Pattern

Clinical Manifestations

Upper respiratory tract infection (common colds, coughing) Lower respiratory tract (pneumonia, bronchiolitis, tracheotracheo-bronchitis)

Other Manifestations

NILE: Nasal flaring & retractions, irritability, lethargy & poor feeding and expiratory wheezing. Perobronchial interstitial pneumonitis is usually present.

Complications

Otitis media (common) Myocarditis (rare)

Diagnosis

Nasal Swab (bronchial mucus culture) Live attenuated vaccines: RespiGam (hyper immune gamma globulin IgG Never give to cyanotic Congenital Heart Disease Rivabirin (virazole) Antiviral (delivered through aerosol, hood, tent or mask) Contraindicated for pregnancy.

Prevention

Treatment

The nurses wearing contact lenses should wear goggles when coming in contact with Rivabirin because the mist may dissolve soft lenses.Note: lenses.Note: American Society of Pediatrics recommend Rivabirin Aerosol could only be administered to:Severely to:Severely ill and immuno-compromised and immunoRSV lower tract disease, CHD, premature infants, chronic lung disease and chemotherapy.Do not give less than 6 months & neurological & metabolic disease

Nursing consideration

Maintain patent airway Best Position - Position the child 30 to 40 degree angle with neck slightly extended to maintain an open airway & decrease pressure in the diaphragm. Second best position - Tripod/Sniffing position Provide cool, moist and humidified O2 Hand washing before and after (10 15 seconds) Wear gloves

12. CROUP disease (Epiglottitis) Causative Agent


Different Croup Types

Haemophilus influenzae or Streptococcus pneumoniae


Acute Epiglottitis (Supraglottitis) Acute Laryngotracheobronchitis Acute spasmodic laryngitis (Spasmodic croup)

Incidence

Occurs frequently between 2 to 5 yrs of age

Initial Signs

High fever; Very sore throat; Upper respiratory tract infection; Respiratory stridor; Hoarse or muffled vocal sounds; Varying degrees of laryngeal obstruction; Respiratory distress.

Cardinal Sign

Hoarseness, resonant cough described as Barking or Brassy Seal Bark and Laryngeal obstruction - an Emergency Situation

Clinical Manifestations:

4Ds (drooling, dysphonia, dysphagia, distress (respiratory) Absence of spontaneous cough, presence of drooling and agitation (Triad symptoms according to Donna Wong)

Late Manifestation

Difficulty breathing (patient may need to sit upright leaning slightly forward to breathe adequately), Stridor (noisy breathing, "crowing" sound when inhaling),Cyanosis (blue skin coloring)

Other Manifestations

Inspiratory Stridor Sore, red & cherry throat Tripod position (sitting upright & leaning forward, with chin thrusts out, mouth open & tongue protruding)

No. 1 Best Position:

Emergency Equipment: Equipment:

Endotracheal intubation or tracheostomy

Screening Test:

Neck X-ray, Complete Blood XCount Throat cultures may identify organisms and their sensitivity to antibiotics as well as rule out diphtheria. A posterior-anterior x-ray of the posteriorxchest may reveal narrowing at the upper airway (steeple sign)

Confirmative Test

Laryngoscopy may reveal inflammation and obstruction in epiglottal; and obstruction in Epiglottal and Laryngeal areas.

Drug Treatment:

Epiglottal swelling, usually decreases after 24 hours of antibiotic Keep the following equipment available in case of sudden, complete airway obstruction: at tracheotomy tray, ET tubes, a handheld resuscitation bag, oxygen equipment, and a laryngoscope with blades of various sizes. Monitor arterial blood gas levels for hypoxia and hypercapnia.

Nursing considerations

Watch for increasing restlessness, rising heartrate, fever, dyspnea, and retractions, which may indicate the need for an emergency tracheotomy. After tracheotomy, anticipate the patients needs because he wont be able to cry or call out, and provide emotional support. Reassure the patient and his family that the tracheotomy is a short-term shortintervention (ussually from 4-7 days). 4Monitor the patient for rising temperature and pulse rate and for hypotension signs of secondary infection.

Clinical Alert: Throat inspection should be attempted only when immediate intubation can be performed if needed.

Maintain patent airway Assess temperature by the axillarys route not oral route Dont force the child to lie down & restrain child Provide cool mist O2 therapy & high humidification to decrease swelling Keep fluids within patients reach and encourage frequent intake Note patient preferences regarding fluids and foods with high fluid content

Maintain accurate intake and output (I/O) and weight daily Monitor urine specific gravity Recommend restriction of caffeine, alcohol; high sugar content food/fluids Review medication and side effects Note signs/symptoms indicating need for further evaluation and Follow-up FollowOther Interventions: Orient patient to environment Use pad and side rails as indicated Assist with activities and transfers as needed

Provide well-fitting environment with decrease of wellstimulation when at risk for tetany, autonomic hyperreflexia Discuss environmental changes necessary to prevent accidents (e.g., decals on glass doors to show when they are closed, lowering temperature on hot water heater, adequate lightning of stairways.

13. HISTOPLASMOSIS
Causative Agent Type of Agent Mode of Transmission Histoplasma capsulatum Fungal infection Inhalation of spores or through the invasion of spores after skin trauma Feces or soil contaminated with feces of birds and bats

Sources of spores

Incidence

common in men Fatal disseminated disease is more common in infants and elderly men

Occurs more in temperate areas of Asia, Africa, Europe, & North and South America Most prevalent in the central and eastern states, esp. in the Mississippi & Ohio river valleys

Predisposing Factor Exposure to spores in people working in the said area (such as that near roosts, chicken coops, barns, and caves and under bridges) Clinical Manifestation Acute onset of fever, hepatomegaly & splenomegaly. No symptoms in some persons. Benign acute pneumonitis in others Chest pain & dyspnea Widespread pulmonary infiltrates

Diagnosis:

Serology test Skin testing Chest x-ray nodular infiltrate similar xwith TB 1. Amphotecirin (Fungizone IV) Given with ASA or acetaminophen prior to start of tx to lessen systemic toxicity BUN & creatinine biweekly (azotemia) Potassium level biweekly Anemia is common

Treatment

2. Ketoconozole (Nizoral) Given orally at bedtime or with meals Toxicity is minimal Nursing Considerations Administer fungicidal medications Monitor breath sounds Encourage coughing and deep breathing Position client in semi-Fowlers semiposition Monitor vital sounds Monitor nephrotoxicity from fungicidal medications Administer O2 as prescribed

14. Cytomegalovirus (CMV)


Type of Agent Mode of Transmission Viral infection Contact with infected secretions (saliva, urine, semen, breast milk, stool, and vaginal cervical secretion of infected persons) High risk are neonate and pregnant woman

Incidence

Predisposing Factor

Immunosuppresed patients, especially those who have received transplanted organs, run a 90% chance of contracting CMV infection. Recipients of blood transfusion from donors with positive CMV antibodies are at some risk. Most patients with CMV infection have mild, non-specific complaints, nonor none at all, even though antibody titers indicate infection. In these patients, the disease usually runs a self-limiting course. self-

Initial Sign:

Cardinal Sign Late Manifestation

Petechial rash Brain damage that may not show up for months after birth. Jaundice, Mental deficiency Hearing loss Virus isolation from saliva, throat, cervix, WBC and biopsy specimens. Indirect immunofluorescent test CMV immunoglobulin M antibody.

Screening Test

Confirmative Test

Complication

Pneumonia is frequent complication GuillainGuillain-Barre syndrome maybe complication of CMV mononucleosis. mononucleosis.

Nursing Consideration

Prevent patient to patient infection spread Provide isolation and standard precaution Ensure that a patient with airborne infections remain in private during hospital stay.

Perform hand hygiene (by handwashing or by use of alcoholalcoholbased solution). Use gloves when handling any body fluids from any patient. Teach the patient and family about: Prophylaxis or immunization, if recommended Monitor temperature, pulse and respirations at intervals. Maintenance of fluid and electrolyte balance. Monitor input and output.

 

  

15. Hepatitis A,B,C,D


Hepatitis a diffuse inflammation of the liver parenchyma, cause by viruses Hepatitis A a form of acute hepatitis occurring either sporadically or in epidemics and caused by viruses introduced by fecally contaminated water or food. food. Young people especially school children are most frequently infected. Hepatitis B a sexually transmitted disease is considered to be the most serious due to the possibility of severe complications such as massive liver damage and hepatocarcinoma of the liver.

 Non A or B Hepatitis- This is also known Hepatitisas Hepatitis C or D which is a viral infection that at present, does not have and identified agent or antigenic markers.

Etiology

Hepatitis A virus it has a spherical structure with a diameter of 20 mm, consists of a single stranded RNA and closely resembles pico navirus particularly enterovirus. Hepatitis B virus contains a molecule of circular double stranded DNA which measures 42 mm in diameter and is called Danes particle after its discoverer. Non A or B Hepatitis- another virus, more than Hepatitis1 virus, that at present does not have an identified agent or antigenic markers, therefore it is diagnose by excluding a HAV and HBV

Predisposing Factors:

Poor sanitation Contaminated water Unsanitary method of preparing and serving of food Malnutrition Disaster and wartime conditions

Mode of Transmission Hepatitis A Usually fecal or intestinal-oral pathway, intestinaloccasionally, parenterally Fecal or oral contact ingestion of infected or contaminated food and liquid Poor sanitation Person to person sexual contact (oral(oralanal)

Hepatitis B From person to person through: Contact with infected blood through broken skin and mucous membrane of the mouth, the rectum and genitals. genitals. Sexual contact via the vaginal and seminal secretions; secretions; Sharing of personal items with an infected person which may cause skin break (razor, nail clipper, toothbrush, etc.)

Parental transmission through: Blood and blood product by transfusion of blood from carrier and non-carriers. non-carriers. Use of contaminated instrument for injection, ear piercing, acupuncture and tattooing. tattooing. Use of contaminated hospital and laboratory equipment such as dialysis apparatus and others. others. Non-A or B Hepatitis NonSame as HBV

Incubation Period Hepatitis A 15-60 days or 3-5 weeks; 153mean = 30 days Hepatitis B 50-180 days or 2-5 months; 502mean = 90 days Non A or B Hepatitis Variable, 2-6 2months; mean = 50 days The difference between hepatitis A, B and C is their incubation period; Hepatitis C has an incubation period of 2-26 weeks. 2-

Signs and Symptoms

Loss of appetite Joint and muscle pain (similar to influenza) InfluenzaInfluenza-like such as headache

Malaise and easy fatigability Anorexia and abdominal discomfort/pain Nausea and vomiting Fever Lymphadenopathy Jaundice accompanied by pruritus and urticaria Bilirubinemia with clay-colored stools clayA client with viral hepatitis is expected to report bloody stool and bleeding gums. A bloody stool is not a sign and symptom of a client with hepatitis.

The indication that client with Hepatitis B needs further health teaching is that it is not contagious once symptom appears. Chronic hepatitis B is treated with interferon alfa2-b with a common side effect of flu-like alfa2flusymptoms. During the ecteric phase of viral hepatitis the client will exhibit yellow sclera.

Management / Treatment

Hepatitis A Prophylaxis I M injection of gamma globulin Complete bed rest Low fat diet but high in sugar Hepatitis B There is no specific treatment. It depends on ones natural body resistance to combat the disease.

Prevention and Control

Hepatitis A Insure safe water for drinking Sanitary method in preparing handling and serving food Proper disposal of feces and urine

Washing hands very well before eating and after using the toilet Separate and proper cleaning of articles used by patient Wearing gloves when giving direct care it is essential that the nurse would indicate precautions in caring for a client with hepatitis A. Telling the family members to wash their hands frequently could prevent transmission of viral hepatitis. To prevent spread of hepatitis A virus (HAV) infection, the nurse is especially careful when emptying the bedpan. Hepatitis B Immunization with Hepatitis B vaccine Wear protective clothing when dealing with blood semen, vaginal fluids and secretions

 Avoid injuries with sharp instruments  Prophylaxis for hepatitis B includes screening of blood donors.

 Observe safe sex practices as: Have sex with only one faithful partner/spouse. Avoid sexual practices, which may break the skin like anal intercourse. Use condom properly. Observe good personal hygiene. Have adequate sleep, rest, exercise and eat adequate nutritious foods to build and maintain body resistance.

 The most appropriate nursing diagnosis for a hepatitis B client who is experiencing fatigue, weakness, general body malaise and tires rapidly during morning care is Activity intolerance related to fatigue.  If a nurse accidentally has had a needle stick in her hands as she pulled an IM injection from the muscle. The first thing that a nurse should do is to scrub the area vigorously with soap and water for 5 minutes,  Hepatitis B is considered to be a sexually transmitted disease.  Non A or B Hepatitis

Same as that for Hepatitis B, although there is no vaccine available for protection against Non A or B Hepatitis. Mandatory screening of blood donors: For HbsAg, 20% For non-A or B, 80% nonDecreasing contact from blood and blood contaminated fluids would prevent the transmission of hepatitis C to health care personnel.

Nursing Consideration

a. Isolation of patient b. Promote rest during acute or symptomatic stage. c. Improve nutritional status. High Carbohydrate, high calorie is the diet given for a client with viral hepatitis. d. Utilize appropriate measures to minimize the spread of the disease. e. Observe for melena and check stool for blood f. Increase inability to carry out activities. g. Decrease in abdominal pain/tenderness h. Recognize that recovery and convalescence are slow and prolonged

Skin care for a client with hepatitis B should be directed towards relieving itching. The nurse planning care for a client with hepatitis A must have an understanding that the causative virus will be excreted from the clients body through feces. If the client who is recovering from Hepatitis A is asking when will my strength return? the response of the nurse would be it is normal for you to feel fatigue, it will soon be gone in about in the next 2-4 months. 2-

Adequate bed rest should be incorporated in giving care for a client with viral hepatitis. In preparing a community education program about preventing Hepatitis B infection. It would be appropriate to incorporate that frequent ingestion of alcohol can predispose an individual to development of Hepatitis B. Serum Transaminase test is used in assessing liver function of a client with viral hepatitis. Prolonged Prothrombin Time should be closely assessed for a client with viral hepatitis.

Hepatitis A Synonyms:
Infectious Hepatitis

Hepatitis B
Serum Hepatitis

Hepatitis C
Post-transfusion PostHepatitis Non-A or non-B Nonnonhepatitis

Hepatitis D
Delta agent Hepatitis

Etiology:

(HAV) Hepatitis A virus

(HBV) Hepatitis B virus Infected Blood Products Drug addicts Sexual contact Contaminated needles Blood or body fluids contact at birth Infected saliva or serum

(HCV) Hepatitis C (HDV) virus Hepatitis D virus Same as HBV primarily through blood Same as HBV via contact with blood and blood product

Predisposing Factors:

Fecal-oral route FecalPerson to person contact Contaminated water or milk Poorly washed utensils

Hepatitis A

Hepatitis B

Hepatitis C

Hepatitis D

Initial Sign:

May occur With or without without symptoms symptoms: flu like illness Headache Fatigue and Malaise Anorexia Fever Brown colored urine Lighter colored stools

Similar to HBV; less severe and anicteric

Similar to HBV

Hepatitis A Cardinal Sign: Expected Abnormal Lab Values:


Jaundice of sclera, skin and mucous membrane Elevated IgM and IgG antibodies AST(SGOT) / ALT(SGPT) initially elevated Alkaline phosphatase slightly elevated Decreased RBC Decreased Serum albumin Elevated bilirubin levels(above 2.5 mg/100ml) Prolonged PTT

Hepatitis B
Arthralgias and rash - Same -

Hepatitis C

Hepatitis D

- Same -

- Same -

Hepatitis A

Hepatitis B

Hepatitis C

Hepatitis D

Screening Diagnostic Tests:

Antibody / antigen test Complete Blood Count Stool Examination Liver Biopsy Liver Scan Urinalysis Presence of hepatitis A virus

- Same -

- Same -

Serologic hepatitis delta virusvirus- detection of hepatitis D antigen and antiantiHDV antibody in the later disease stage.

Confirmatory Test:

Hepatitis B surface antigen

Anti-HCV Anti-

Presence of hepatitis D virus

Hepatitis A Therapeutic Diet:


Small frequent feedings Supplemented if necessary by intravenous infusion of glucose High carbohydrate Low fat

Hepatitis B
Proteins restricted High carbohydrate Low fat

Hepatitis C
High carbohydrate Low fat Largest meal in morning because nausea intensifies as they progresses Small, HighHighcalorie, highhighprotein meals Parenteral feeding (if appropriate) (Nurses 3 min. clinical ref. By Gloria F. Donnely p.257)

Hepatitis D
Chronic liver disease Fulminant hepatitis Mild or asymptomatic form of HepaB that flares into severe, progressive and chronic active hepatitis and cirrhosis

Hepatitis A
Acute Fulminant Disease Complication: Hepatitis Aplastic anemia Hemorrhagic perforation Pneumonia Peritonitis Thrombophlebiti s Pancreatitis Myocarditis

Hepatitis B
Fulminant hepatitis Chronic Liver Disease Cirrhosis Primary hepatocellular carcinoma Aplastic anemia Syndrome resembling serum sickness characterized by arthralgia or arthritis, rash, & angioedema; can lead to misdiagnosis of Hepa B as rheumatoid arthritis or Lupus erythematosus Primary Liver Cancer (Nurses 3 min. clinical ref. By Gloria F.

Hepatitis C
Chronic liver disease Cirrhosis Primary hepatocellular carcinoma

Hepatitis D
Chronic liver disease Fulminant hepatitis Mild or asymptomatic form of HepaB that flares into severe, progressive and chronic active hepatitis and cirrhosis

Hepatitis A

Hepatitis B

Hepatitis C

Hepatitis D

Best Drug:

Virazole R (ribavirin)

Virazole R (ribavirin) Acute stage of viral hepa B Anti-viral Anti-

Rebetron (ribavirin)

Nature of Drug:

Anti-viral Anti-

Anti-viral Anti-

Major Side Effects:

Nausea and vomiting Headache and depression Rash and hair loss

- Same -

- Same -

Nursing Diagnosis:

Fatigue related to decreased metabolic energy production and altered body chemistry as evidenced by reports of lack of energy and decreased performance Altered nutrition, less than body requirements related to anorexia, nausea and vomiting as evidenced by aversion to eating /lack of interest in food, loss of weight and poor muscle tone Knowledge deficit regarding condition, prognosis, treatment, self care and discharged needs as evidenced by questions and statements of misconception

Nursing Intervention:

 

  

 

Follow the protocol for use of universal precautions Educate the patient and family members about preventing transmission, including use of universal precautions, hand washing and personal hygiene Provide adequate rest period for the patient based on the severity of symptoms; increase activity as tolerated Administer medications such as antiemetics, as ordered, to combat nausea Assess the patient for nutritional needs Instruct patient to avoid close personal contact and sexual activity with others until test results are negative Emphasize the importance of rest to reduce the metabolic demands of the organ Encourage oral fluid intake. (Nurses 3 min. intake. clinical ref. By Gloria F. Donnely p.257)

ROCKY MOUNTAIN SPOTTED DISEASE


Etiology: Initial Sign: Rickettsia Rickettsii
Generalized, excruciating headache Nausea and Vomiting Aching in the bones, muscles, joints, and back Headache Photophobia

Mode of Transmission

Incidence

Prolonged bite (4-6 hrs) of an adult (4tick Inhalation or through contact of abraded skin with tick excreta or tissue juices This explain why people should not crushed ticks between their fingers when removing) Higher in children ages 5 to 9, men and boys, and whites Prevalent in the continent of United States, particularly in southeast and southwest

Predisposing factor  travel to a tick infested area  outdoor activities such as camping and backpacking #1 Sign: Desquamation of the upper and lower extremities

Late Manifestation:

Anorexia Constipation Abdominal Pain Hepatomegaly Splenomegaly Insomnia Restlessness Extreme Cases Delirium Nursing Alert: A Rapid pulse rate and hypotension Systolic pressure less than 90 mmHg Held imminent death from Complete Vascular Collapse

Screening Test:

Laboratory Test Serologic Test RMSF Diagnostic exam

Confirmative Test: Complication:

Presence of tick on the fingers

Pneumonia Renal Failure Death Otitis Media Parotitis

Nursing Diagnosis: Early Diagnosis is an important determinant of outcome. The Patient with Headache and Febrile illness is important.

Nursing Intervention:

         

Decrease Fever, Restlessness, and pain. Cover it with a thick ointment to lessen the thick hold on the skin. Disinfections and the hands are washed. Put on strict isolation immunosuppressed or patient with disseminated disease. Apply wet, cool dressing to pruritic lesions. Compress of NSS of aluminum acetate of the lesions- are soothing. lesionsAnalgesics may be necessary for weeks or even months after the blisters dried up. Keep the blister-covered with a sterile blisterpowder especially after they break. Prevent possible entry of bacteria in the lesions. Encourage use of gown, mask and proper disposal of secretions.