Communicable Diseases• Communicable disease are most often the leading cause

of illness in our country today• Knowing what type of communicable disease could

prevent a health care provider from acquiring or harboring the disease

COMMON TERMS• Epidemiology – science that study the patterns of

health and disease, its occurrence & distribution for the prevention and control of disease.

• Sporadic – occasional or intermittent occurrence of disease with no specific pattern

• Endemic - constant or continuous occurrence of disease • Epidemic – sudden increase in # of cases in short

period of time, an outbreak• Pandemic – worldwide epidemic • Attack rate

• is the number of cases developing in a group people who were exposed to the infectious agent

• Morbidity rate• calculated as the number of cases of illness

given time period divided by the population at risk.

• Mortality rate • the percentage of population that dies from

disease• incidence

• described as the number new cases in a specific time period in a given population risk

• way of measuring the risk of an individual contracting the disease

• Prevalence• reflects the number of total existing cases (both

old and new) • useful to assess the overall impact of the

diseases on society• Outbreak

• generally implies a cluster of cases occurring during a brief time interval and affecting a specific population

The Infectious Process• For an infection to occur a process involving six links or

steps must be present• A. if any of the links are missing, the infection will not

occur• B. Infection control measures can interrupt the process

by eliminating one or more of the steps.

INFECTIOUS DISEASE PROCESS or CHAIN OF INFECTION• Infectious Agent • Reservior • Portal of Exit• Route of Transmission of MO• Portal of Entry• Susceptible Host

Six links form the chain of infection

1. Infectious agent (Microorganism): Bacteria, virus, fungi, etc.• A. Capability of producing an infection depends on:• i. Virulence and number of organisms present• ii. Susceptibility of the host.• iii. Existence of portal of entry• iv. Affinity of host to harbor MO

2. Reservoir: Provide survival for organism• People, equipment, water, etc.• A. Appropriate environment for growth and multiplication

of microorganism must be present.• B. Reservoir include respiratory, gastrointestinal,

reproductive and urinary tracts, and the blood3. Portal of exit

• Allows the microorganism to move from reservoir to host ( includes excretions, secretions, skin, droplets)

4. Route of transmission of MO (five routes)• Types of transmission of pathogens:

– Horizontal transmission• from one person to another through

contact, ingestion of food or water, or via a living agent such as insect.

– Vertical transmission

• from a pregnant woman to fetus, or from a mother to her infant during childbirth

• Three Primary routes (Contact, droplet and airborne)• Two lesser routes ( Vehicle and vector)

Primary Routes• A. Contact- most frequent source of nosocomial infection• 1. Direct contact- transmission body to body and physical

transmisssion (sexual intercourse, kissing or touching)• 2. Indirect contact- contact with contaminated

intermediate object ( needle, dressing or dirty hands)• B. Droplet- transmission of large particle droplets ( larger

the 5 microns) Diphtheria, pertusis, pnuemonia, etc.• C. Airborne- transmission of small particle droplets or

residue of 5 microns ( measles, varicella, TB)

Two lesser routes• Common Vehicle: transmission by contaminated items

such as food, water or devices.• Vector borne: Mosquitoes, fleas, rats, etc.

5. Portal of entry• Mucous membrane, gastrointestinal (GI) tract,

Genitourinary (GU) tract, Respiratory tract, Nonintact skin

6. Susceptibility of the host• A host who is immunosuppressed, fatigue,

malnourished, weakened by other diseases, elderly, stressed, or hospitalized with wounds, IV’s and catheters are at high risk.

TRIAD OF DISEASE CAUSATION – Epidemiologic Triad

1. Host (suscepibility)- intrinsic or extrinsic characteristics2. Agent3. Environment- Medium for culture of MO and MOT

Characteristics of an Agent• Infectious dose – number of causative agent• Pathogenecity – ability to cause the disease• Virulence / Potency – extent/severity of toxin quality• Antigenecity – ability to stimulate an anti-body response

Viruses• can only multiply in living things as its reservoir • can pass through the filters of the body, Blood

Brain Barrier & Placenta Barrier• self limiting • lasts for a specific length of time with or without

treatment,

• patients are treated according to the symptoms• it’s the body’s own resistance that will fight the

infection• Bacteria

• can multiply in both living and non-living things• can not pass through the filters of the body

except for Treponema Palladium causing Syphilis which passes the placental barrier after the 16th week (4th month of pregnancy)

• INFECTIOUS DISEASES – disease caused by living MO which may not be transmitted through ordinary contact.

• CONTAGIOUS DISEASES – are diseases that can be easily transmitted.

• All communicable diseases are infectious but not all are easily transmitted

• All infectious diseases are communicable but not all are contagious

• All contagious diseases are both communicable and infectious

Stages of Communicable Disease• Communicabilty period- entry of MO• Incubation period – time interval from the 1st exposure

from disease to appearance of the 1st s/sx.• Prodromal – time interval from the 1st s/sx to

appearance of the characteristics sx of the disease.• Stages of Illness – period when the characteristic sx of

the disease are manifested by patient and others.• Convalescence – period of recovery, s/sx are gradually

disappearing

3 Nursing Concerns in Dealing with a Patient with Communicable Disease

• Know the causative agent• Know what body secretions harbour the MO• Know the mode of transmission

General nursing Care for Patients with Communicable Diseases

• Preventive Aspect- Health education- Immunization- Environmental control- Proper Supervision of Food Handlers- Control Aspect- Isolation- Quarantine- Disenfection - Medical asepsis

I. Preventive aspect

A. Health Education

Goal: The person will have a change of KSA which eventually lead to a change in behaviour towards health or do some modification of behaviour.

-doctor is the primary giver of health education (main responsibility)

-nurse is the key provider of information

B. Immunity/ Immunization

• Immunity - state of being resistant to infection or a state of being free from infection

• Immunization – the process of rendering immunity to an individual

2 types of Immunity

1. Active immunization occurs when a person’s own immune system is activated and generates a primary immune response.

a. Natural Acquired Active Immunity – the body will contracts the disease and recovers

b. Artificial Acquired Active Immunity- chemically killed bacteria, weakened forms

- vaccine, toxoid

2. Passive immunization - receives antibodies that were created in another person or animal.

a. Naturally Acquired Passive Immunity – maternal transfer of antibodies (IgG/IgA)

b. Artificially Acquire Passive Immunity – intentionally given for immediate protection from infection (ex: human immunoglobulin, human serum, anti-toxin, anti-tetanus)

3 Laws of Immunization:

1. Expanded Program on Immunization (EPI) – PD #996

2. UN Goal: Universal Child Immunization (UCI) –Proclamation #6

3. Health for Filipino CY 2000: National Immunization Day (NID) – Proclamation #46

Goal: To prevent the 7 Childhood Diseases for children under 5 years old

TB – BCG, DPT – DPT vaccine, Poliomyelitis – OPV, Hepatitis B , Measles

4 Temporary Contraindications for Immunization

• pregnancy

• immunocompromised

• very severe disease

• recently received blood products

2 Permanent Contraindications for Immunization

• Allergy

• encephalopathy without known cause or convulsions within 7 days after pertussis vaccine

C. Environmental Sanitation

1. PD 856 – integrated all those working in night clubs and beer gardens to submit themselves for STD exams at least once a month and for gonorrhea at least twice a month.

2. PD 825 – anti-littering law or proper disposal of garbage

Fine: P2,000-5,000 or 6 months-1year imprisonment

D. Proper Supervision of Food Handlers

1. DOH responsibility

2. BFAD – monitor food and drugs for safe consumption

• II. Control Aspect – there is already infection but control or limit the spread of infection

• A. Isolation - separation of the infected person based on the longest period of communicability of the disease.

• Strict isolation – protecting other person by containing the MO within the patient

• Reverse Isolation – protecting the patient wherein MO will be away from the patient

2 Revised Isolation Precaution to be practiced

1. Standard Precaution

2. Transmission Based Precaution

1. Standard Precaution – the primary strategy for preventing nosocomial infection

• applies to all pts regardless of their dx

• applies to all body fluids, secretions and excretions except sweat

• applies to non intact skin and mucous membrane

Elements of Standard PrecautionCDCCenters for Disease Control and Prevention

• Handwashing

• Wear gloves if there is a possibility of direct contact with blood or bodily secretions

• Gloves must be worn when in contact with items or surfaces soiled with blood or body fluids

• Removal of false fingernails

• Protect clothing with gowns or plastic aprons if there is possibility of being splashed or direct contact with contaminated material

• Wear mask and/or goggles or face shields to avoid being splashed, suctioning, irrigations, during OR and deliveries

• Do not break needles into receptacles; rather discard them intact and uncapped into containers

• 2. Transmission Based Precaution – is instituted to patients with highly transmissible infections. Precautions are beyond the set for the standard precautions.

3 Ways to Practice Transmission Based Precaution:

• Airborne Precaution – use of respiratory protection such as use of special types of mask = ultra filter mask or particulate mask

• Droplet Precaution – use ordinary mask and goggles

• Contact Precaution – use of gloves and gowns

• B. Quarantine – limitation of freedom of movement of a well person during the longest incubation period;

- quarantine of person with no disease but were exposed.

• C. Disinfection – killing/destruction of pathogen by mechanical or chemical

2 Ways of Attaining Disinfection:

• Concurrent – done when a person is still the source of infection

• Terminal – done when the patient is no longer the source of infection

• Sterilization - killing of all MO including spores

• Disinfestation - destruction of MO, insects, rodents or animals that are living in the human habitat that can transmit disease to man.

• Fumigation – killing of arthropods and rodents using gaseous agents

D. Medical Asepsis

• Hand washing – the no. 1 principle

• Use of protective barrier (PPE)

• Placarding – no smoking sign

Integumentary System

Measles

-aka RUBEOLA, Morbilli, Little Red Disease, 7 day measles, 9 day measles, Hard measles of First Disease

- death is usually due to complications (pneumonia)

- affects children < 2y/o, malnourished

CA: Paramyxovirus – rubeola virus

MOT: Droplet spread or direct contact in some instances it is Airborne

Incubation period- 10 days from exposure

1. Pre-eruptive Stage – highly contagious stage

- high grade fever – 3-4 days

- 3 C’s – cough, colds, conjunctivitis

- (+)Stimson sign / measle eye – puffiness of the eyelid with linear congestion of the lower conjunctiva

- Photosensitivity

- (+) enathem, fine red spot (grayish pecks) at the center found in the inner cheek just opposite the molars

- (Koplik’s spot) –pathognomonic

2. Eruptive Stage

– Rashes appear on the 3rd day - maculopapular, reddish, and blochy

– cephalo-caudal in distribution

3. Post-eruptive Stage

– fine, branny desquamation – peeling off

from red color rashes, it will fade to brown then peel off excluding skin

• Diagnostic Examination: by clinical observation and physical examination

• Medical Management: symptomatic – viral infection

– Vit A – to prevent xeropthalmia

– antibiotic

Nursing Care

• strict isolation

• increase or maintain body resistance

• keep patient warm and dry

• hygienic measures – eye care, ear care, oral care, skin care

• Immunity : Gives permanent immunity

• It is highly contagious during 4 days before the appearance of rashes and 5 days after the appearance of rashes

Preventive Measures

• Avoid MOT

• Immunization with Anti-measles vaccine (AMV) – 9 months old, 0.5cc SQ deltoid muscle

– child may experience fever, mild rash formation 3-4 days after

– allergy to eggs and neomycin → anaphylaxis

– don’t get pregnant within 3 month

• proper disposal of nasopharyngeal secretions

• covering of mouth and nose when sneezing and coughing

German Measles

• aka Rubella, 3 day disease

• CA: Pseudoparamyxovirus = Rubella or Togavirus

• MOT: Droplet, direct,

3 Stages of German Measles:

1. Pre-eruptive Stage

– presence or absence of fever, if (+) 1-2 days

– mild cough or mild colds

Eruptive Stage

• (+) enanthem– seen at the soft palate, maculopapular, pinkish or reddish, discrete or finer to look at

• (Forsheimer’s spot) - pathognomonic

• Cephalocaudal

• Lymphadenopathy

• 3. Post-Eruptive Stage – occurs after 24 hours where rashes starts to disappear and enlarge lymph nodes subsides

• Laboratory Exam

• Rubella Titer test – to determine the titer of antibodies to german measles

• If given to women who wants to bear a child à wait for 3 months

Treatment

• Medical and Nursing treatment : Supportive care

• Immunity: Gives permanent immunity

Preventive Measures

• Avoid MOT

• Immunization: MMR

• It is communicable during the entire course of the disease = 3 days

• Not fatal but could be fatal on a pregnant woman- it affects fetal growth

4 Possible Major Congenital Anomaly

• Microcephaly

• Congenital Cataract

• CHD – Tetralogy of Fallot

• Deafness and Mutism

• If pregnant and exposed to german measles, give gamma globulin 1 amp within 72 hours – gives temporary immunity

Chicken Pox

• aka varicella

• CA: Varicella zoster virus

• MOT: Airborne, direct contact, droplet

• Duration of sickness: 2 weeks

3 Stages Chicken Pox

1. Pre-Eruptive - (+) or (-) of low grade fever, body malaise, musle pain, HA lasting for 24-48 hours

2. Eruptive Stage

begins as a macule, 5-10 crops → papule →vesicle → pastule

rashes are classified as vesiculo-pastular

rashes have generalized distribution all over the body (trunk and scalp 1st)

contagious from the time rashes appear until the last rash have dried or crusted

centrifugal in spread of rash

3. Post-Eruptive Stage – rashes starts to dry/crust and peel off by itself

Management

Diagnostic Examination: by clinical observation and physical examination

Medical:

treated symptomatically

Anti-viral agent – Zovirax (Acyclovir)

Anti-histamine

Nursing Care

skin care to prevent infection

increase resistance and adequate rest and nutrition to prevent encephalitis

Immunity: Gives permanent immunity

Avoid MOT

Immunization using Varicella vaccine (Viravax) given 12 months old, 0.5cc SQ deltoid

If <13 y/o – single dose ; if > 13y/o – 2 doses, 1 month interval

Proper disposal of nasopharyngeal secretions

Cover mouth and nose when sneezing and coughing

Herpes Zoster

• aka SHINGLES, Zona, Acute Posterior Ganglionitis

• adults are usually affected

• CA: inactive or dormant type of chicken pox

• MOT: Airborne or droplet

• Duration of Illness – 2 weeks

Signs and Symtoms

• (+) vesiculo-papular rashes- painful rather than itchy bec it affects nerve endings and that pain persists within 2 months even if patient had recovered.

• unilateral distribution of rashes

• period of communicability is the same as chicken pox when all rashes have dried

Management

• Diagnostic Examination: Clinical observations and physical examination

• Potassium Permanganate (KMNO4) with 3 Fold EffectS:

• A- Astringent ---dries rashes

• B- Bactericidal ---decrease chance of skin infection

• Oxidizing ---deodorizes the rashes

• analgesic for pain

• Zovirax can also be given

• Nursing Care and Preventive Measures: same as Chicken pox

Nervous System

Tetanus

• aka Lock Jaw

• CA: Clostridium tetani – anaerobic, non-motile, spore-forming

• Normal habitat: intestines of plant eating animal

• Break in the skin

• MO stays in the wound à releases toxins à travel to the blood à produces s/sx

• New born – umbilical cord (tetanus neonatorum)

• Children – dental caries

• Adult – any king of wound

• Toxins released by MO are:

• Tetanolysin – dissolves RBC causing anemia

• Tetanoplasmin – brings about the muscle spasm affecting the myonueral junction and internuncial fibers of the brain

• Immunity: No permanent immunity

s/Sx:

– Trismus – lock jaw

– Risus sardonicus- sarcastic smile

– Opisthotonus- arching of the back

– Intermittent muscle spasm ,(+) boardlike rigidity on the abdomen

– Extension of the extremities (gastrocnemius)

– Diaphoresis

– Low grade fever

– Type of contraction: tonic

3 Objectives in Nursing Management of tetanus:

1. To prevent pt from having spasm –

Exteroceptive stimuli – coming from external/outside environment

Interoceptive stimuli – coming from within the pt., fatigue, stress

Proprioceptive stimuli – there is participation of pt and another person

Isolation is to prevent exposing pt to the stimuli despite being not communicable.

2. To prevent pt from having injury

a.Respiratory injury

1. Prevent airway obstruction - padded tongue depressor, O2 administration – cyanosis during spasm

2. Prevent respiratory infection

3. Prevent respiratory aspiration

b. Fracture – due to restraining when having spasm

3. To provide comfort measures

- provide dark, quiet room – prevent stimuli

- Proper wound care

Avioid MOT

Immunization

DPT 6 weeks after birth for 3 doses at 1 month interval (0.5ml VL)

Health teaching: fever, swelling and tenderness, signs of convulsions w/in 7 days

Tetanus Toxoid given to pregnant women on the 2nd tri-mester of pregnancy, 2 doses

Tetanus Toxoid given for persons in high risk to tetanus

Rabies

• aka Hydrophobia and Lyssa

• disease of low form of animal that is accidentally transmitted to man through animal bites

• An acute form of encephalitis

• CA: Neurotropic virus

Rhabdovirus – transferred from animal to man

2 Pathways for Virus to Travel:

Rhabdovirus

↓

Peripheral Nerves

↓ CNS

↓

Efferent nerves

↓

Salivary glands and to other organs

• Inclusion bodies develop called Negri Bodies - pathognomonic

• MOT: Contact with saliva of a rabid animal, scratching, licking of wound by dogs

• Incubation Period: animals = 3-8 weeks; humans = 10 days-years

2 Stages of Manifestations in Animals

1. Dumb Stage - depressive stage, manic behaviour

2. Furious Stage – agitated, fierceful, drooling of saliva → will die.

3 Stages of Manifestation in Human

1. Invasive Stage – virus is transferred through saliva by direct or indirect contact

• S/Sx:

• numbness on site, sore throat, marked insomia, restlessness, irritable & apprehensive

• flu-like symptoms, slight photosensitivity

2. Excitement Stage – patient is confined in the hospital

• S/Sx:

• aerophobia and hydrophobia

• drooling of saliva and spitting

• photosensitive

• maniacal behaviour

• Management: Haloperidol with Benadryl

• 3. Paralytic Stage – when spasm is no longer observed because paralysis sets in and within 24-72 hours → patient dies.

Diagnostic Examinations:

• Brain Biopsy of Animal

• Direct Flourescent Antibody Test (DFAT)

• Observation of animal for 10 days

• Factors to consider in observing the animal:

• Site of the bite

• Extent of the bite

• Reason for the bite

Medical Management

1. Vaccine – post exposure prophylaxis only

• Active form of Vaccine

a. Purified Duck Embryo Vaccine (PDEV) – Lyssavac

b. Purified Vero Cell Vaccine (PVCV) – Verorab

with in 24 hours

c. Purified Chick Embryo Cell Vaccine – (PCEV)

• 2 Ways of Administration: IM or ID

• Passive form of Vaccine

a. Equine Rabies Immunoglobulin (ERIg) – from animal serum

b. Human rabies Immunoglobulin – human serum

Nursing Care

• Wash wound with running water

• Seek consultattion asap.

• Place patient in dim and quiet room

• Room of patient should be away from sub-utility room

• Wear complete protective barriers when entering the room

Preventive Measures:

• Keep away from stray dogs

• Keep animal caged or chained

• If bitten – wash with soap and running water, use strong antiseptic solution and observe the dog

Meningitis

• inflammation of the meninges

• CA:

Viruses – CytoMegaloVirus – viral meningitis

Fungus – Cryptococccal meningitis

Bacteria – common cause

TB meningitis, streptococcal meningitis, hemophilus influenza B

Meningococcal Meningits Spotted fever / Meningococcemia

• highly fatal and highly contagious type of meningitis

• vascular system is affected resulting to vascular collapse (DIC)

• Waterhouse Friedrichsen Syndrome – caused by massive invasion of blood by meningococcus infection resulting in organ failure, coma or even death, unless effective antibiotic or tx is quickly rendered

• Rifampicin 450 mg once/day x 3 days

• Ciprobay 500 mg once/day x 3 days

• CA: Neisseria Meningitides

• Incubation Period: 2-10 days

• Portal of Entry: Respiratory system via the nasopharynx

• Neisseria Meningitides à Nasopharynx à Blood stream

•↓

• Vascular changes (petechiae, echymossis)

• ↓

• Meningeal irritation manifested by:

• nuchal rigidity/stiffneck (1st sign of meningitis)

• AbN reflexes – (+) kernig’s sign, (+) brudzinki’s sign (pathognomonic sign)

• ↓

• Incresed ICP -----CsF in subarachnoid space

• ↓

• severe HA

• projectile vomiting

• altered VS:increase temp, decrease PR, decrease RR, increase systolic but N diastolic

• convulsions

• diplopia – optic nerve/disc

• tinnitus, difficulty of hearing/deafness, loss of balance, vertigo

• altered LOC

• Others/sx: anorexia, gen body malaise and loss of apetite

Diagnostic exams:

• Lumbar Puncture (L3 & L4) – tap or aspirate CSF to

a. Color: yellowish, turbid/cloudy

b. increased CHON, increased WBC, decreased sugar

c. C & S – to determine CA and specific drug to kill the MO

d. Counter Immuno Electrophoresis (CIE) – if clear CSF either viral or protozoa

• Blood culture – done if lumbar puncture cant be done yet bec MO travels to the blood stream

• Antimicrobial drugs

a. Viral – supportive

b. Fungus – antifungal

c. Bacteria – antibiotic

• Corticosteriods – Dexamethasone or Solu-Cortef

• Mannitol - osmotic diuretic, removes CSF

- monitor I/O, assess effectiveness of drug

- assess hydration

• Anticonvulsant drug – Phenytoin (Dilantin)

• Symptomatic and supportive

• if phenytoin is given IV, it should be sandwich with NSS (NSS-Dilanti-NSS) à can cause crystallization when mixed with CSF

• if per orem, do oral care and gum massage à gingival hyperplasia

• Preventive Measures: Proper disposal of nasal secretions, covering of mouth and nose, avoid MOT

• Immunity: No permanent immunity

Poliomyelitis

• aka Infantile Paralysis or Heine-Medin’s dse

• high risk – below 10y/o

• CA: Legio Debilitans virus

Type 1 – Brunhilde – common in the Phil.

Type 2 – Lansing

Type 3 – Leon

• Early Stage: Nasopharyngeal secretions

MOT: droplet

Port of Entry: respiratory system by nasopharynx

• Late Stage: found in stool

MOT: fecal-oral route

Portal of entry: digestive system by mouth

Stages of Poliomyelitis:

• Invasive or Abortive –stage when virus invades the host

- flu-like sx, non-specific

• Non-paralytic – slight CNS involvement

- hump temp curve

- (+) Poker spine - stiffness of the back (opisthotonus) with head retraction

- spasm of the hamstrings

- hypersensitivity of the skin (hyperparesthesia)

- (+) babinski reflex,

Paralytic Stage – severe CNS involvement

- flaccid (soft, flabby and limp) paralysis – pathognomonic sign

4 Types

• Bulbar – CN9 (glossopharyngeal) and 10th (vagus) affectation

- swallowing, vocal cord and respiratory paralysis

• Spinal – c0mmon type, AHC affectation

- paralysis of U/L extremities – uni or bilateral

- intercostal muscle paralysis

• Bulbo-spinal – CN and AHC are both affected

• Landry’s – ascending paralysis (quadriplegia)

Diagnostic Exams:

• Lumbar Puncture Test – Pandy’s Test – increased CHON, increased WBC, N sugar

• Muscle testing – test for threshold for pain

• EMG

• Stool exam – (+) all throughout the process

• Throat swab – maybe (+) in 2 weeks of the dse course

• Supportive and Symptomatic

• Preventive Measurement:

1. Immunization: OPV – Sabin Vaccine, given 6 weeks after birth

Instructions to mothers:

a. Don’t feed child 30 mins before administration

b. If vomiting occurs, repeat dose

c. Be careful in handling the stool of the child who had received OPV

d. for immunocompromised – give Inactivated Polio Vaccine (IPV-Salk Vaccine) – 0.5 cc IM, VL in 3 doses at one month interval

2. Avoid MOT

Circulatory System

Dengue

• CA: Arbovirus-Dengue virus

West Nile virus

Flavivirus

• MOT: biological transmitter – Aedes Aegypti

mechanical transmitter – Celux fatigan

• day biting and low flying mosquito

• breed in clear stagnant water

• urban area

• white stripes on legs, gray wings

Mosquito (Aedes Aegypti)

↓

Bloodstream

↓

Creates multiple lesions in the bloodstream

----------------------------------------------------

↓ ↓

↑ capillary fragility ↑ capillary permeability

( easily bleeds ) (allows shifting of fluid fr 1 comp to another)

↓↓

Thrombocytopenia edema, ascites, and hemoconcentration

• Grade 1

a. fever – 3-5 days

b. HA; periorbital, abdominal, joint and bone pains

c. N/V

d. pathological vascular changes: petechiae and Herman sign (generalized flusing/redness of the skin

e. diagnosed as Dengue Fever or Dandy Fever or Breakbone Fever

• Grade 2

a. persistence of s/sx of Grade 1 + Bleeding

b. bleeding from: 1. nose – epistaxis

2. gum - gum bleeding

3. stomach -

4. hematemesis, melena, hematochezia

• Grade 3

a. persistence of s/sx of Grade 2 + Circulatory Failure

b. cold clammy skin

c. check for capillary refill

d. hypotension, very rapid weak pulse and rapid respiration

• Grade 4

a. persistence of s/sx of Grade 3 + Hypovolemic Shock → Death

• Torniquet Test or Rumpel Leede Test - presumptive

• Test for capillary fragility

• 3 Criteria before performing Torniquet test

1. 6 months or older

2. fever > 3 days

3. (-) signs of DHF- fever of 3 days

• Release the cuff, check and count the petechial formation per one square inch (>20 petechial formation = (+) tourniquet test

• Platelet Count - ↓ in DHF – definitive test

• Hematocrit (Hct) determination - ↑ in DHF due to hemoconcentration

• Symptomatic treatment

• Antipyretic – but never give Acetyl Salicylic or Aspirin (ASA)

• Reye’s Syndrome – a neurologic d/o associated with viral infection (<12y/o)

• Vit K (Aquamephyton, Phytomenadion, Synkavit and Konakion)

• Vit C

• Blood Transfusion

• 1. To prevent and control bleeding

a. Epistaxis

b. Gum Bleeding

c. Hematemesis

d. Melena

• Supportive & Symptomatic

• Increase body resistance – proper nutrition and adequate rest

• Preventive Measures:

CLEAN Program of DOH

C- hemically treated mosquito net

L- arva eating fish

E- nvironmental Sanitation

A- nti mosquito soap/off lotion

N- atural mosquito repelant trees

• Immunity: No permanent immunity

Malaria

• aka AGUE

• king of tropical diseases manifested by indefinite period of fever and chills

• CA: Protozoa – Plasmodium,

1. Plasmodium Vivax

2. Plasmodium Falciparum – most fatal

3. Plasmodium Malariae

4. Plasmodium Ovale

- Only female mosquitoes suck blood

- P. Vivax and P. Falciparum – common causes of

malaria in the Phils.

• MOT: mosquito bite, blood transfusion

• Night biting from dusk til dawn

• Breeds in a clear slow flowing water

• Rural areas – mountains and forest

• Lands on surface – 45 degrees angle/slanting

If infected by mosquito

↓

Blood stream

----------------------------------

↓ ↓

RBC is penetratedLiver

(MO reproduce) (MO stay for 3-5years)

↓

RBC

Nursing Care:

• Cold Stage – shaking of body & chattering of lips (10-15mins)

• Hot Stage – fever, chills, vomiting, abdominal pain (4-6 hours)

Nursing Care:

• Wet Stage – profuse sweating, feeling of weakness

Nursing Care: Make patient comfortable

Keep patient warm

Increase fluid intake

• Cerebral Hypoxia – caused by P. falciparum causes anemia

• Diagnostic Examinations:

1. Malarial Smear/ Blood Smear – blood is extracted at peak of fever

2. Quantitative Buffy Count (QBC) – no need for the height of fever to set in

• Medical Management:

1. Chloroquine (Aralen) – mainstay

2. Other Drugs: Primaquine, Atabrine, fansidar and Quinine (reserve drug for severe cases)

• Used cautiously for pregnant women

• Immunity: No permanent immunity

Tuberculosis

• aka Kokh’s Infection, Phthisis, PTB, Galloping Consumption

• CA: Acid Fast Bacilli - M. Tuberculosis, M. Bovis, M. Avium/Avis

• MOT:

1. Airborne and droplet

2. Ingestion of infected milk of cows

3. Blood – TB meningitis, TB of bones, TB of the spine

• Incubation Period: 1-2 months (4-8 weeks)

• S/Sx:

1. low grade fever with night sweats

2. anorexia and weight loss

3. fatigability

4. chest pain and dyspnea

5. dry cough à productive (yellowish/greenish) à blood streak sputum/hemoptysis – pathognomonic sign

6. back and epigastric pain

7. anemia and amennorhea in female

• Tuberculin skin testing – screening, ID

- a presumptive test

- Mantoux test – most reliable skin test for TB.

- 0.1 cc Purified Protein Derivative, volar aspect

- bleb or wheal formation

=<or = to 4mm à negative

= 5-9 mm à doubtful (repeat the test)

= > or = 10mm à positive

• Sputum Examination – confirmatory, done in 3 series

• 3. Chest X-ray - not definite test, tells only the extent of involvement of the lungs

• According to extent of disease based on cavitations within the lungs

a. Minimal

b. Moderately advanced

c. Advanced – (+) of cavitations within the lungs

• According to clinical manifestations

a. Active PTB

b. Inactive PTB

• According to American Pulmonary Society

a. TB 0 – (-) exposure (-) infection (-) tuberculin testing

b. TB I- (+) exposure (-) infection (-) tuberculin testing

c. TB II – (+) exposure (+) infection (+) tuberculin testing (-) s/sx

d. TB III – (+) exposure (+) infection (+) tuberculin testing (+) s/sx

• Short Course Chemo therapy – Rifampicin, Isoniazid, Pyrazinamide Ethambutol (RIPE)

a. Isoniazid (INH) – mainstay drug

- 6mons for carrier & inactive adult patient

- 9mons for children

- 12mons for immunocompromised patients

Side Effects: 1. Peripheral neuropathies/neuritis

a. Foods rich in Vit B6 (pyroxidine)

2. Hepatotoxicity – (+) jaundice

a. Monitor liver enzymes

b. Avoid alcohol

b. Rifampicin (R) – causes orange color of tears, urine and stool

c. Pyrazinamide (P)– causes hyperurecemia

d. Ethambutol (E)– causes irreversible optic neuritis that brings about blindness

• 2. Standard Regimen(SR) – Streptomycin, Isoniazid & Ethambutol (SIE)

a. Streptomycin (S)

Side Effects: 1. Nephrotoxicity

2. Ototoxicity – CN8 (tinnitus/vertigo)

• 3. Directly Observed Treatment Short Course (DOTS) WHO- “tutuk gamutan”

5 Elements:

1. Political will to support the program

2. Microscopic availability

3. Steady supply of medicine

4. Personnel – RN and midwife

5. Documentation and recording

D – iet - small frequent nutritious foods

D – rugs - adequate drugs and emphasize importance of compliance

R – est - conserve energy

• Contraindicated Nursing Care: Do not do chest physiotherapy

• Avoid MOT

• Immunization with BCG immediately after birth 0.5cc ID ® deltoid area

Instruction to mothers: don’t massage the area, (+) fever, (+) abscess formation on

the site of injection →scar

• Proper disposal of nasopharyngeal secretions

• Covering of mouth when sneezing

• Immunization : Gives temporary immunity

Diphtheria

• acute contagious dse char by generalized toxaemia coming from a localized inflammatory process known as PSEUDOMEMBRANE.

• CA: Corynebacterium diphtheria or Klebs-Loeffler bacillus

• MOT: Droplet (direct contact) – affects all ages

• Nasal

- dryness, excoriation of upper lip and nares

- (+) of pseudomembrane in the nasal turbinate– pathognomonic sign

- grayish-white membrane with leathery consistency

• Pharyngeal – (+) bullneck appearance (enlargement of the cervical lymphnode)

• Laryngeal – (+) respiratory distress

- (+) hoarseness/aponia

- (+) laryngeal stridor – brassy metallic cough

• Nose and Troat Culture

• Shick’s Test – to determine resistance or susceptibility to diphtheria

• Moloney’s Test – to determine hypersensitivity to diphtheria

*Removal of the pseudomembrane is not encouraged à facilitate bleeding and fast regrowth

• Neutralize toxin

ADS – IM,IV ANST; if (+) give in fractional dose – desensitization

IV fluid to dilute toxin

• Antibiotic – Penicillin

• Supportive – O2 inhalation, tracheostomy

• Strict Isolation – highly contagious

• CBR – to limit the circulation of toxin

Myocarditis, bronchopneumonia & peripheral neuritis – fatal complications

• Diet: Liquid to soft diet. (-) spices , small frequent feeding, observe strict aspiration precaution, increase fluid intake

• Provide diversional activities for children

• Avoid MOT

• Immunization: DPT 0.5cc IM VL

6,10,14 wks of age simultaneous with OPV

- do not massage area to prevent lump formation (press)

- (+) lump à hot moist compress

- (+) fever – give paracetamol; cooling measures

• Adverse side effect: CONVULSION

• Nsg Mx: take temp accurately to differentiate it from febrile convulsion

Pertusiss

• aka as Whooping cough and Chin cough

• affects below 6 y/o

• CA: Coccobacillus -

a. Bordetella pertussis

b. Hemophilus pertussis

• Incubation Period: 7-10 days

• MOT: Droplet

• 1. Catarrhal stage – highly contagious, child stays at home

• s/sx: 1. (+) of colds

• 2. nocturnal coughing

• 3. fever

• 4. tiredness and listlessness

• 2. Spasmodic or Paroxysmal stage

• s/sx:

• a. 5-10 successive forceful coughing which ends in a prolonged inspiratory phase or whoop

• b. (+) production of mucus (tenacious) plug on airway passage

• c. other manifestations

- congested face, tongue

- teary eyes with protrusion of eyeball

- distended face and neck veins

- involuntary mict. and defecation

- abdominal/inguinal hernia

- deafness due to hemorrhage of vestibular apparatus of ear

• 3. Convalescent stage – s/sx starts to disappear

• - patient no longer communicable and on road to recovery

• Nasal Swab

• Bordet-Gengou Test

• Agar Plate – use nasopharyngeal secretions

• Cough Plate

• Medical

1. Immunization: Pertussis Immune Globulin

2. Antibiotics: Erythromycin

3. Fluid and Electrolyte Replacement

4. Mild form of sedation: Codeine

• Nursing Care:

1. CBR

2. Maintain F&E balances

3. Provide adequate nutrition

4. Proper positioning when feeding

5. Provide abdominal binder to prevent hernia

• Preventive Measures: same as Diptheria

• Immunity: No permanent immunity

Typhoid Fever

CA: Salmonella typhosa →Payer’s patches

MOT: Fecal-oral

Sources of infection: feces, fingers, food, flies and fomites

1. Prodromal Stage – (+) MO in the blood stream

- fever, dull HA, N/V, abd pain, diarrhea or constipation

2. Fastigial/Pyrexial - MO invades the payer’s patches

Features:

1. rose spots in the the abdomen –pathognomonic sign

2. ladder like fever

3. splenomegaly

4. Typhoid psychosis – due to release of toxins

a. coma vigil look

b. difficulty in protruding the tongue

c. carphologia – involuntary picking up of linen

d. sabsultus tendinum – involuntary twitching of tendon

3. Defervescence Stage – (+) ulcer formation àintestinal perforation à bleeding àspillage in peritoneal cavity

S/Sx of Peritonitis:

1. sudden and severe abd pain

2. persistence of fever

3. board-like rigid abd

4. Convalescent /Lysis Stage – s/sx starts to subside

still have to observe for relapse

1. Blood Culture

a. Widal Test

Antigen O (AG O) or Somatic Antigen = presently infected

Antigen H (Ag H) or Flagellar Antigen = previously exposed to TF or has had an immunization

b. Thypi dot – uses blood specimen where it identifies antibodies

• 2. Stool and Urine Exams

• Medical:

• Antibiotic – Chloramphenicol

• Nursing Care:

1. Fluid and Electrolyte Management

2. Provide adequate nutrition – (+) vomiting-small,freq meals; (+)diarrhea-(x) fatty food

3. Provide comfort measures

Leptospirosis

• aka Mud fever, Swamp fever, Canicola fever, Pre-tibial fever, Weil dse, Swineherd dse and Ictero-Hemorrhagica dse

• Source of infection: Excreta of rats particularly urine

• CA:

1. Leptospira (spirochete) – bacteria

2. Leptospira canicola

3. Leptospira hemorrhagica

4. Leptospira enterogans – common in Phils.

• MOT: Skin penetration

• Incubation Period: 2 dyas to 4 weeks

• People at risk: sewage workers, farmers, miners, people living in Manila areas

• Incidence: rainy seasons

• striated muscles

• liver

• kidneys

• fever, HA, vomiting

• myalgia and myositesàcalf muscles

• jaundice with hemorrhages on skin & mucous membrane icter-hemorrhagic à yellow and red orange skin, orange eyes à pathognomonic sign

• Diagnostic Examination:

• 1. Blood culture Leptospira agglutination test (LAT)

• Leptospira antigen-antibody test (LAAT)

• Microscopic agglutination test (MAT)

• Medical Management:

• 1. Antibiotics – Tetracyline à drug of choice

• - not given to a. child <8y/o àstaining of teeth

• b. pregnant women – teratogenic effect àbone defect

• - never give tetracycline with calcium rich food, antacid and iron prep & milk

• 2. Give Penicillin to patient allergic to tetracycline

• - give 1hr before meals or 2hrs after meals or empty stomach

• Nursing Care: Symptomatic

1. Provide eye care

2. Warm compress for muscle pain

3. I/O,consistency, frequency & amt

• Preventive Measures:

1. Environmental sanitation by eradication of rats

• 2. Avoid walking through floods

Hepatitis

• inflammation of the liver

Hepa A Hepa B Hepa C 1. Synonym

Infectiuos Hepa, Catarrhal Jaundice, Epidemic Hepa

Serum Hepa, Homologous Hepa, Viral Hepa

Post-transfusion Hepa

2. Source of Infection

Feces Blood,semen,cervical secretions

Blood

3. Causative agent

HAV or RNA cointaining virus

HBV of DNA containing virus

HCV

4. MOT Fecal-oral Person-person, parenteral/ percutaneous, placental

percutaneous

5.Incubation Period

2-7 wks 6wks-6mons 5wks-7-8 wks/12wks

6. Risk Crowding, homosexuals, food handlers, poor sanitation, unsafe water supply, children

Multiple sex partners, members of medical team, blood, drug addicts

Blood recipients

7. Carrier

state

No No Yes

8.

Prognosis

0.5%

mortality

1-10% mortality 1-2%

mortality 9. Prevention

Proper handwashing, sanitation, screen food handlers, enteric precautions

Screen blood donors

Screen blood donors

1. Pre-Icteric Stage – S/Sx:

fever

RUQ pain

fatigability, weight loss, body malaise

N/V, anorexia

signs of anemia

2. Icteric Stage – (+) jaundice – inability of liver to eliminate (N) amt of bilirubin

(+) pruritus

urine is tea colored or brown

passing out of alcoholic or clay colored or no color stool

persistence of sx of pre-ecteric stage but to a lesser degree

3. Post-Icteric Stage – jaundice and other s/sx starts to disappear

- energy starts to increase and patient is on the road to recovery

- it takes 3-4 months for the liver to recover (avoid alcohol for 1year and ASA & acetaminophen)

1. Liver Enzyme Test – determine extent of liver damage

ALT, AST, GGT, ALP, LDH

2. Serum Antigen- Antibody (Ag-Ab) Test

a. Hepatitis A

- Hepatitis A Surface Antigen = (+) 2 wks after exposure to HepA

- Anti- HAV

b. Hepatitis B

- Hep B Surface Antigen (HBsAG): (+) acute hepatitis B

- Hep B Protein Independent Antigen (HBeAa)= (+)chronic hep B

3. Routine Test

a. Bilirubin Testing

b. Prothrombin Time Testing (PTT)

c. Ultrasound or CT Scan of Liver

d. Urinalysis

• Medical

1. Hepatic Protectors or Liver Aides contain vitamins, minerals and phospholipids

a. essentiale for adults

b. Jetepar or Silymarine for pedia

2. New trends in treating Hepatitis

a. Antiviral : Lamivudine

b. Immuno-modulating drug: Interferon

• Nursing Care:

1. Provide rest to promote liver regeneration

2. Low fat diet, High CHON intake to spare protein metabolism

In US, “butterball” diet

• Immunization: Hep B vaccine is given at 6 wks after birth, 3 doses at one month interval, Dose: 0.5cc IM, VL

• Avoid MOT

• Immunity: Don’t give a permanent immunity

•

Gonorrhea

– aka Jack, Gleet, Clap, Strain, GC and Morning Drop

• CA: Neisseria Gonorrhea

• MOT: Sexual Contact, transferred to baby during birth

• Incubation Period: 3-21 days

• Manifestation: Male- Urethritis

Female – Cervicitis

• For Male:

– dysuria

– redness & edema of urinary meatus à acidic urine passes through àburning sensation à (+) pain

– purulent urethral discharges abundant in the morning – morning drop

– abscess forms on the prostate gland à prostitis à epidydimitis à formation of scar on epidydimis à obstruction flow of the sperm cellàsterility

• For Female:

– dysuria and urinary frequency

– itchy, red and edematous meatus, if cervix is affected

– burning pain and purulent discharges, if urethra is affected

– abscess forms on the bartholin’s and skene’s gland à endocervitis & endometritis

– (+) narrowing of fallopian tube à sterility

• If pregnant, it will cause: ectopic pregnancy or opthalmia neonatorum

• C&S by mucosal scrapping

• Pap Smear or Vaginal Smear

• Medical Management: Antibiotic

a. Ceftriaxone (Rocephin)

b. Doxycycline (Tetracycline)

• Psychological aspect of care – low self-esteem

• Health education: - safe sex, monogamous relationship, masturbation

use of condom, behaviour modification

Syphilis

• aka Pox, Lues, SY, and Bad Blood Disease

• CA: Treponema Pallidum – a spirochete that passes to the placental barrier during the 16th week of pregnancy (2nd & 3rd trimester)

• MOT: Sexual contact, vertical transmission

• Incubation period: 10-90 days

• 1. Primary Stage

• a. Chancre, a painless popular lesion on face, lips, tongue, under the breast, fingers and genitals

• b. Regional lymphadenopathy

2. Secondary Stage: highly infectious & contagious

a. fever & malaise

b.skin rashes & dermatitis: dry, hard, wart like lesions à Condyloma lata

c. Oral mucous patches

d. alopecia – patchy, polka dot or moth eaten appearance of hair and thinning of pubic hair

3. Tertiary Stage –

a. Gumma – infiltrating lesion found on deeper tissues & body organs such as skin, bone and liver

b. aortitis & aneurysm

c. paresthesia, abnormal reflexes, dementia and psychosis

• C&S by mucosal scrapping

• Dark Field Microscope

• Serologic Test

• Flourescent Treponema Antibody Absorption Test – confirmatory test

• Medical :

Antibiotic: Benzathine Penicillin G (Penadur)

• Nursing Care & Preventive Management: same as gonorrhea

HIV infection means one is infected with AIDS Virus

• AIDS = infected by virus + incompetent immuno-response

• CA: Human Immuno-Deficiency Virus (HIV) retrovirus

• MOT: BT, sexual contact,

exposure to infected blood, products or tissuesvertical (mother-child) or

Perinatal (pregnancy,delivery&breastfeeding)

sharing needles

• Incubation Period: 6 mons – 7 years

MOà detected by macrophageàalert T Cells

↓

HIV ← Antibodies ← stimulate B cells

• fever with night sweats without a cause

• enlargement of the lymph nodes without a cause

• fatigability

• weight loss

• altered sleeping patterns

• temporary memory loss

• altered gait

Adults: 2 Major sxs and 1 Minor sx

Children: 2 Major sxs and 2 Minor sxs

3 Major Sx: 1. fever – 1 month & above

2. diarrhea – 1 month & above

3. 10% weight loss/ stunted growth for pedia

6 Minor Sx: 1. persistent cough – 1 month & above

2. persistent generalized lymphadenopathy

3. generalized pruritic dermatitis

4. oropharyngeal candidiasis

5. recurrent herpes zoster

6. progressive dessiminated herpes zoster

Opportunistic Infection:

• TB is the most common of the Avium Type (from birds)

• PCP

• CMV

• CNS à lungs à eyes

• Cancer : Kaposi Sarcoma à malignancy of blood vessel (skin) – appearing as pink/purple painless sots on the skin called Leopard Look

• Enzyme Link Immunoassorbent Assay (ELISA) Test – screening test

• Western Blot – confirmatory

• CD4 and T cell count

- if more than or equal to 200 à HIV infected

- if less than 200 à AIDS

Nucleus Analogs prevent the virus to multiply during the initial phase of cell division

a. Nucleoside Reverse Transcriptase Inhibitor (NRTI)

1. Azidothymidine (AZT) – Zidovudin, retrovir

2. Lamivudine -3#TC, Epion

3. Stavudine – Cd4T, Zerit

4. Dideoxyinosine (DDI) - Didanosine

4. Dideoxycytidine (DDC) – Zalcitabine, Hivid

b. Non-Nucleoside reverse Transcriptase (NNRTI)

a. Delavirdine

b. Nevirapine

2. Protase Inhibitor (PI) prevets virus to multiply during the last phase of call division

a. Indinavir

b. Retonavir

c. Saquinavir

d. Nalfinavir

3. Fusion Inhibitor- Fuseon (Enfuritide)

• Promote knowledge and understanding

• Promote quality of life

• Provide self care and comfort

• Preventive Measures:

• 1. Practice ABCD of HIV: A – bstinence

B – e faithful

C – ondom

D – on’t use drugs

• 2. Education

• 3. Counselling

• 4. Behavior Modification