This area focuses on the nursing care of patients with infections of body systems such as acquired immunodeficiency syndrome (AIDS), cytomegalic inclusion disease, encephalitis, epiglottitis, gram-negative sepsis, hepatitis, herpes viruses (including varicella), human immunodeficiency virus (HIV), infectious gastroenteritis, Legionnaires' disease, Lyme disease, meningitis, mononucleosis, mumps, otitis media, pertussis (whooping cough), rabies, rheumatic fever, rubella, rubeola (measles), salmonella, sexually transmitted diseases (STDs), shingellosis, urinary tract infection, and tuberculosis.
A. Theoretical framework - basis for care
1. Types of infectious and communicable disease
Infections and communicable diseases can be studied base upon the nature of the organism such as bacterial, viral or fungal for example; based upon the nature of the resulting disease such as respiratory tract or gastroentestinal tract disease for example; or based upon the vector of transmission such as blood and body fluid, respiratory secretions or body drainage for example.
Nationally Notifiable Diseases, 1996 (get new)
Acquired immunodeficiency disease (AIDS)
Anthrax
Botulism
Brucellosis
Chancroid
Chlamydia trachomatis...
a. Diseases transmitted via the blood and body fluids (for example: AIDS, hepatitis type B)
STDs
Gonorrhea, syphilis, chancriod, granuloma inguinale, and lymphogranuloma venereum are the five classic venereal disease transmitted through sexual contact. A broader classification of sexually transmitted diseases (STD) includes not only the five classic diseases but also others such as trichomoniasis, chlamydial infections, and genital herpes, as well as Human Immunodeficiency Virus (HIV) with the follow on disease state of Acquired Immunodeficiency Syndrome (AIDS) Hepatis type B, C and D also boarder on this category.
Acquired Immunodeficiency Syndrome (AIDS)
Human Immunodeficiency Virus (HIV)
Hepatitis Type B
Hepatitis B virus (HBV) is a hepadnavirus which can result in cronic infection, especially in infants. 90 to 95% of adult patients recover completely; however, 80 to 95% of infants and young children develop a cronic carrier state, and are at high risk for developing hepatocellular carcinoma.
Rapid developing fulminant hepatitis is associated with 70 to 90% mortality, with survival of those over 40 year of age uncommon. Fulminant HBV is also associated with superinfection with other agents, including HDV.
Clinically, HBV is frequently subclinical with an insidious onset, following a varying incubation period from 50 to 180 days, averaging 60 to 90 days, which makes for the infections origin difficult. In the adult, infection is not apparent at rate of 65 to 80 per cent.
Transmission is via blood primarily and body secretions secondary. Incubation time is related to the exposure dose of HBV.
A vaccine is available. Hepatitis B immune globulin (HBIG) is effective on exposure but effectiveness is decreased if delayed greater than three days. It provides no preexposure prophylaxis value due to the effective and available vaccine.
In the infant borne to a mother who is infected during pregnancy, or is a carrier of HBV, both HBIG and HBV vaccine is given at different sites within a few hours of birth to reduce mother to infant transmission. A second dose at one month and a third at six months of age are given.
Hepatitis type D (Delta Hepatitis) (HDV) is found in conjunction with HBV infection. It is associated with a higher rate of liver damage and mortality in HBV infection group. Resolution of HBV infection results in resolution of HDV as well. Because of the need for coinfection with HBV, this vaccine is effective.
Hepatitis C
A flavivrus, hepatitis C virus (HCV) is transmitted through blood products and to a lesser extent, body substances. Mother to infant transmission is less than for HBV. HCV infection is usually subclinical but more than half HCV infections progress to chronic hepatitis. No vaccine is available.
b. Diseases transmitted via respiratory secretions (for example: tuberculosis, mononucleosis, streptococcal infections, rubeola [measles], varicella, Haemophilus influenza)
Bacterial
Tuberculosis -
Viral
Upper Airway Infection
Mononucleosis - Epstein -Barr Virus
Respiratory Syncytial Viral infection (RSV)
Reye's Sybdrome
Rheumatic Fever
streptococcal infections strptococcal pharyngitis
Group A beta-hemolytic streptococcal infections
Carditis
Pancarditis
Epiglotitis
Roseola Infantum
Rubella
Rubeola (Measles)
Diphtheria
Pertussis (Whooping Cough)
Mumps
Polymyelitis
Varicella (Chicken Pox)
Herpesvirus Varicella-Zoster (Shingles)
Haemophilus Influenza
c. Diseases transmitted via the body drainage and secretions (for example: conjunctivitis, nosocomial infections, staphylococcal infections, herpes simplex, STDs)
Conjunctivitis
Nosocomial Infections
Urinary Tract Infection (UTI)
Nephritis: pyelonephritis (acute)
Nephritis: Glomerulonephritis (chronic)
Pseudomonas
Staphylococcal infections
pneumonia
osteomyelitis
STDs
AIDS
gonorrhea
syphilis Primary secondary
herpes symplex Genital herpes Herpes simplex II
UTI
giardias
chlamydia
Trichomoniasis
Cytomegalovirus (CMV) ??
Pelvic inflammatory disease (PID)
d. Diseases transmitted via the gastrointestinal tract (for example: infectious diarrhea, salmonella, shingellosis, hepatitis type A, helminthic diseases)
infectious diarrhea
Escherichia coli
Escherichia coli are one of the large group of heterogeneous enteric gram negative rods, enterobacteriaceae. It is part of the normal flora of the intestines. Normally do not cause disease, but become pathogenic in other areas, such as the urinary tract, where it is the leading cause of UTI.
E coli of different groups are responsible for a number of diarrheal diseases. For example:
Enteropathic E coli (EPEC) has been previously associated with nursery diarrhea outbreaks in developed countries, and is an important cause of infant diarrhea in developing countries. Self limited watery diarrhea is the usual result of EPEC infection. Antibiotics shorten the diarrhea course and cure EPEC infection.
Enterotoxigenic E coli (ETEC) probably cause 50 to 65% of traveler's diarrhea., as well as being an important cause of infant diarrhea in developing countries. ETEC produce a heat labile exotoxin (LT) which results in hypersecretion of water and chlorides as well as inhibiting reabsorption, resulting in diarrhea. LT stimmulates antibodies, with the people who reside in the areas where ETEC is prevelent in the water supply, as in developing countries, having antibodies lessening their risk for diarrhea on reexposure.
With some ETEC strains, a heat stable enterotoxin (STa) as well as LT, with a sever diarrhea resulting.
Enterohemorrhagic E coli (EHEC) strains have become an Emerging Infectious Disease (EID), in particular the serotype E coli O157:H7. Producing an afebrile hemorrhagic diarrhea, and as a serious complication, hemolytic uremic syndrome (HUS) characterized by blood in the urine and kidney failure, E coli O157:H7 is an occasional non pathogenic resident of animal intestines but with poor slaughtering techniques the beef is contaminated, and with human ingestion disease results. Disease may also result from water supplies contaminated by cattle feces. Children and the elderly are especially prone. Termed hamburger disease, because the contaminated ground meat is mixed into the center and may survive in an under cooked meet paddy, proper through cooking reduces risk.
Salmonella typhimurium Typhoid (Salmonellosis) Typhoid fever
Giardia
shingellosis
hepatitis type A
Spread by the fecal oral route, including contaminated water, the hepatitis A virus (HAV) is a picornavirus of the genus Hepatovirus, with only the one serotype known. HAV can be destroyed by boiling water for five minutes, and by cooking meat to greater then 85 oC (> 185 oF). Surfaces need to be cleaned by 10% (1:10 dilution) of chlorine bleach. HAV is resistant to the normal concentrations of chlorine used for water disinfectant.
HAV, like other hepatitis viruses, starts with gastrointestinal symptoms of nausea, vomiting and anorexia with mild fever; however, onset is abrupt with HAV but insidious with other hepatitis viruses. Jaundice may occur. Disease is mild for children and may not be noticed, but adults experience a more sever process. Relapse may occur 1 to 4 months later. Recovery confers life long immunity. A persistent carrier state has not been detected, and seams unlikely. Protective immune globulin is available for HAV, and provides protection for several months. An inactivated vaccine is available.
Hepatitis type E (HEV), originally classified as an NANB, is transmitted enterically by the fecal oral route, and resembles HAV infection but is not serologically related. Similar to HAV, cronic liver disease does not result; however, in the pregnant female a 20% mortality rate exists.
helminthic diseases
Food Borne diseases
salmonella shingellosis hepatitis type A
Clostridium perfrigens
Contamination of meat with the animal abdominal contents during the slaughtering process sets the process for Clostridium perfringens food poisoning. With the cooking process, oxygen levels are lowered and the spores germinate. With a generation time of 20 minutes, meat dishes such as pies and stews allowed to remain warm provide ideal growing medium. With ingestion, the organism sporulate in the intestines, producing a toxin which results in marked hypersecretion in the jejunum and ileum producing diarrhea. Onset of diarrhea is usually within 6 to 12 hours, and symptoms do not usually include vomiting or fever.
Vibrio and viruses
Staphylococcus aureua
A short incubation period of 1 to 8 hours before the onset of symptoms characterizes Staphylococcus aureus food poisoning. S aureus produces a toxic that is heat stable and can survive boiling for 30 minutes; however, foods prepared in advance and not properly stored chilled before serving are the usual source. Large masses left to cool slowly, and room temperature cooling are other sources. Competing organisms are killed through the cooking process, allowing food then contaminated by S aureus allows bacterial proliferation with the cooling and improper storage at room temperature. Reheating does not destroy the toxin The toxin directly stimulates the vomiting reflex center, producing the usual first symptom, followed by abdominal cramps and diarrhea. Recovery is usual within 24 hours. The process is afebrile.
Clostridium botulinus
Cholera
botulism
Other
H pilori
Helicobacter pylori, a gram negative spiral shaped rod, is found associated with peptic, gastric and duodenal, ulcers. Since the rate of infection is greater than incidence of related ulcers, other factors are involved such as susceptibility with type O blood.
Prevalence increases with age with 30% under 30 and 40 to 60% over 60. Developing countries have a adult rate of over 80%. Rates are higher in lower socioeconomic groups. Intrafamilal clustering occurs. Acute epidemics of gastritis are associated with H pylori, and suggest a common source, and fecal oral transmission route. Infection may persist for years or life.
H pylori produces urease, neutralizing acid. Damage to the mucus layer occurs.
Triple therapy of metronidazole, and either bismuth subsalicylate or bismuth subcitrate (Pepto-Bismol�) with either amoxicillin or tetracycline for 14 days results in 70 to 95% effective eradication. With Eradication of H pylori results in ulcer disappearance. Recurrence is low. Early treatment decreases antibody response and those individuals are thought to be at risk for subsequent reinfection.
Rapid tests are available. Breath test has the individual swallow radioactivity labeled urea, with 30 minutes later, radioactivity labeled CO2 can be detected in the breath.
Legionnaire's Disease Legionella pneumophila
Otitis media
Meningococcal infections Haemophilus influenzae
Toxic shock syndrome
Candidiasis
Septic shock (bacteremia)
Encephalitis
Hookworm, Pediculosis, pinworms, roundworms, trichinosis
Lyme disease
histop;asmosis
toxoplasmosis
Rocky Mountain Spotted fever
Tetanus
rabies
anthrax
2. Clinical manifestations of infectious and communicable diseases
a. Altered respiratory functioning (for example: increased secretions, presence of abnormal breath sounds, cough, dyspnea, tachypnea)
b. Altered gastrointestinal functioning (for example: anorexia, nausea, vomiting, diarrhea, melena)
Peritonitis
c. Altered genitourinary functioning (for example: frequency, urgency, flank pain, hematuria, pyuria, dysuria, vaginal or penile discharge)
d. Altered integument (for example: rash, vesicles, macules, swelling, pruritus, erythema)
e. Altered vital signs (for example: fever, tachycardia)
f. Alterations in comfort (for example: pain, fatigue, anorexia, insomnia)
g. Alterations in mental status (for example: confusion, slowed thought processes)
3. Factors influencing the patient's response to infections and communicable diseases
a. Age and physiological factors (for example: active and passive immunity)
b. Psychological factors (for example: stress, cognitive ability)
c. Socioeconomic and cultural factors (for example: health practices. lifestyle, nutritional status, environmental factors, substance abuse)
d. Presence of other illness (for example: patient with diabetes, patient with leukemia, patients receiving immunosuppressive drugs, patient receiving antibiotic therapy, patient with an opportunistic infection)
Since the spleen is important in the filtering process removing microorganisms from the blood, individuals who have had their spleen removed or in the case of sickle cell disease have a non functioning spleen, are at risk for infection due to bacteriemia especially from pneumococci and salmonellae.
e. Causative agent (for example: bacteria, viruses, other pathogens)
f. Site of infectious or communicable disease
g. Extent or severity of involvement (for example: local vs. systemic infection)
4. Theoretical basis for interventions related to infectious and communicable diseases
a. Medications (for example: antibiotics, antifungal agents, anti-inflammatory agents, antipyretics, antiviral agents, antidiarrheal agents)
b. Immunizations (for example: mumps, measles, rubella (MMR); diphtheria, pertussis, tetanus (DPT); Haemophilus b, polio, hepatitis B vaccine)
c. Preventive measures (for example: tuberculosis screening, health teaching, sex education, proper nutrition, universal precautions, body substance isolation)
B. Nursing care related to theoretical framework
1. Assessment - gather and synthesize data about the patient's health status in relation to the patient's functional health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: subjective symptoms, nutritional status, medications, past illnesses, health habits, family history, allergies, occupation, social habits, previous exposure to causative agents)
2) Assess factors influencing the patient's response to infectious and communicable diseases (see IA3)
3. Obtain objective data related to the patient's infectious and communicable disease problem (for example: determine clinical manifestations, altered vital signs, alterations in the integument)
4) Review laboratory and other diagnostic data (for example: complete blood count [CBC], rubella titers, VDRL, sputum for acid-fast bacilli, culture and sensitivity reports, Mantoux test, sedimentation rate, diagnostic radiology and imaging modalities, serum screening for hepatitis viruses, human immunodeficiency virus [HIV])
b. Synthesize assessment data (see IB1a [1-4] above)
2. Analysis - identify the nursing diagnosis (patient problem) and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example: risk for infection related to decreased immune response; risk for infection related to presence of indwelling catheter; risk for social isolation related to environmental stimuli; impaired skin integrity related to pruritus; knowledge deficit: unprotected sexual practices)
b. Set priorities For example: based on Maslow's hierarchy of needs, based on the patient's developmental level)
c. Establish expected outcomes (patient-centered goals) for care (for example: patient will be afebrile, patient will verbalize preventive measures, patient's skin will remain intact)
3. Planning - formulate specific strategies to achieve the expected outcomes
a. Consider factors influencing the patient's response to the health problem in planning the patient care (for example: stress reduction measures, age-related factors, immune status [see IA3])
b. Plan nursing measures on the basis of established priorities to achieve the expected outcomes (for example: monitor hydration status, alleviate skin discomfort, provide protective isolation)
4. Implementation - carry out nursing plans designed to move the patient toward the expected outcomes
a. Use nursing measures to control the spread of the causative organism (for example: universal precautions, isolation techniques, personal protective equipment, protective barrier techniques, body substance isolation, environmental considerations)
b. Use nursing measures to promote, maintain, or restore physiological functioning (for example: provide adequate fluids for a patient with infectious gastroenteritis, provide skin care for a patient with varicella, establish a rest schedule for a patient with mononucleosis, make dietary adjustments for altered elimination patterns)
c. Use nursing measures to minimize patient discomfort (for example: provide a sitz bath for a patient with vaginitis, provide skin care for a patient with pruritus, provide a cool, nonstimulating environment for a patient with meningitis)
d. Use nursing measures specific to prescribed medications (for example: assess vital signs prior to the administration of analgesics, monitor temperature following the administration of antipyretics, assess for allergies prior to the administration of antibiotics, administer urinary analgesics to relieve dysuria, apply skin preparations to relive itching, administer antiviral agents to inhibit infection, monitor for adverse reactions)
e. Use nursing measures to assist the patient and/or significant others to cope with the health problem (for example: use therapeudic communication techniques with the patient and/or family, refer the patient with AIDS to a support group, make referrals to community health agencies for patients with tuberculosis)
f. Provide information and instruction (for example: emphasize the need for protective asepsis, instruct the patient about the need for proper nutrition, instruct the patient with an STD about prophylactic measures, provide instruction about hygienic practices, instruct parents about the need for their child to complete the course of antibiotic therapy, advise the patient with hepatitis type B to refrain from donating blood)
5. Evaluation - appraise the effectiveness of the nursing interventions relative to the nursing diagnosis and the expected outcomes
a. Assess and report the patient's response to nursing actions relative to the expected outcomes (for example: decrease in wound drainage, decrease in pain to otitis media, effects of antipyretic medication, condition of the skin, alterations in the patient's condition, patient verbalizes the intention to practice safe sex, patient verbalizes knowledge of the route of transmission, patient with tuberculosis adheres to medication regimen)